Who should I name as my healthcare agent?

Choose someone who (1) understands your values and wishes; (2) can handle emotionally difficult decisions under pressure; (3) will advocate for your wishes even if family members disagree; (4) is geographically accessible; and (5) is willing to serve in this role. Common choices include a spouse, adult child, sibling, or close trusted friend. Always ask the person before naming them.

Does a healthcare POA need to be notarized?

It depends on the state. Some states require notarization; others require two witnesses; others require both. Review your state's specific requirements. When in doubt, having both witnesses and notarization provides the broadest legal protection.

Does my healthcare POA work in other states?

Most states recognize healthcare POAs executed in other states if they were valid under the laws of the state where they were signed. However, some states have specific requirements that may affect how the document is interpreted. If you spend significant time in multiple states, consider having a healthcare POA that meets the requirements of each relevant state, or consult an attorney.

Can I revoke my healthcare power of attorney?

Yes. You can revoke a healthcare POA at any time as long as you have the mental capacity to do so. You can revoke it in writing, by executing a new healthcare POA (which automatically supersedes the old one), or by communicating your revocation verbally to your healthcare provider. You should notify your agent and all healthcare providers in writing of the revocation.

Free Healthcare Power of Attorney Template — Fill Out & Download Instantly

Free — No Sign-Up RequiredPDF & WordUpdated April 6, 2026

A healthcare power of attorney (also called a medical power of attorney or healthcare proxy) is a legal document that designates a trusted person (your agent or proxy) to make medical and healthcare decisions on your behalf if you become unable to make those decisions yourself due to incapacity, illness, or injury. The agent steps in to communicate with doctors, consent to or refuse treatments, authorize hospitalizations, arrange for home health care, and make other healthcare decisions consistent with your known wishes.

⚠️ Legal Disclaimer: This template is attorney-reviewed and built to US legal standards. It does not substitute for professional legal advice. For complex situations, we recommend consulting a licensed attorney.

Document Completeness0%

State*

Healthcare POA requirements vary significantly by state — this document is tailored to your state's general requirements

Principal's Full Legal Name (You)*

Principal's Address*

Agent's Full Legal Name*

Agent's Address*

Agent's Phone Number*

Successor Agent Full Name

Backup agent if primary agent cannot serve

Successor Agent Address

Powers Granted to Agent*

List the specific healthcare powers your agent may exercise

Limitations on Agent's Authority

Specify any treatments or decisions your agent is NOT authorized to make

End-of-Life Wishes

Describe your wishes regarding life support, artificial nutrition, pain management, and hospice care

Organ and Tissue Donation*

Execution Date*

MM/DD/YYYY

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HEALTHCARE POWER OF ATTORNEY

(Durable Power of Attorney for Healthcare)

State of [State]

NOTICE TO PRINCIPAL

This is an important legal document. Before signing this document, you should know these important facts: You are creating a healthcare power of attorney and giving your named agent broad powers to make healthcare decisions for you. Your agent may exercise these powers if you become unable to make or communicate your own healthcare decisions. You have the right to revoke this document at any time. This document shall not affect your right to consent to treatment while you are able to do so. This document becomes effective only when your attending physician determines that you lack the capacity to make healthcare decisions.

DESIGNATION OF HEALTHCARE AGENT

I, [Principal's Full Legal Name (You)], residing at [Principal's Address], hereby appoint the following person as my agent to make healthcare decisions for me:

HEALTHCARE AGENT (PRIMARY):

[Agent's Full Legal Name]

[Agent's Address]

Phone: [Agent's Phone Number]

DURABILITY

This power of attorney shall not be affected by my subsequent incapacity or mental incompetence. It is my intention that this document constitute a durable power of attorney for healthcare as defined by the laws of the State of [State], and that it remain effective notwithstanding any future incapacity.

HEALTHCARE DECISIONS — POWERS GRANTED

Subject to any limitations in this document, I grant my agent full power and authority to make healthcare decisions for me to the same extent that I could make such decisions if I had the capacity to do so. The powers I grant my agent include but are not limited to:

[Powers Granted to Agent]

My agent is authorized to:

(a) Consent to, refuse, or withdraw consent to any healthcare;

(b) Access, receive, and disclose my health information under HIPAA;

(d) Authorize transfer between healthcare facilities;

(e) Make decisions regarding hospice and palliative care;

(f) Take any other actions necessary to carry out my healthcare wishes.

LIMITATIONS ON AGENT'S AUTHORITY

My agent has no limitations beyond those required by applicable law.

END-OF-LIFE INSTRUCTIONS

My agent shall make end-of-life decisions consistent with my known values and the best information available about my prognosis, using their best judgment to choose the course of action I would want under the circumstances.

ORGAN AND TISSUE DONATION

Organ Donation Preference: [Organ and Tissue Donation]

EFFECT OF DEATH

Upon my death, my agent's authority shall terminate, except that my agent shall have the authority to make decisions regarding organ donation consistent with my stated preferences above.

REVOCATION

I may revoke this healthcare power of attorney at any time and in any manner, including by written revocation, oral revocation communicated to my healthcare provider, or by executing a new healthcare power of attorney.

EXECUTION

I sign this Healthcare Power of Attorney on [Execution Date].

_________________________________________

[Principal's Full Legal Name (You)] (Principal)

STATEMENT OF WITNESSES

We declare that the person signing this document is personally known to us or provided satisfactory proof of identity, that they signed this document in our presence, and that they appear to be of sound mind and under no duress, fraud, or undue influence. Neither of us is the person appointed as agent in this document.

WITNESS 1:

_________________________________________

Signature

Printed Name: _____________________________

Address: __________________________________

Date: _____________________________________

WITNESS 2:

_________________________________________

Signature

Printed Name: _____________________________

Address: __________________________________

Date: _____________________________________

NOTARY ACKNOWLEDGMENT

STATE OF [State]

COUNTY OF ____________________________

On [Execution Date], before me personally appeared [Principal's Full Legal Name (You)], known to me or proved by satisfactory evidence, and acknowledged this Healthcare Power of Attorney as their free and voluntary act.

_________________________________________

Notary Public, State of [State]

My Commission Expires: ___________________

[SEAL]

Document Completeness0%

State*

Healthcare POA requirements vary significantly by state — this document is tailored to your state's general requirements

Principal's Full Legal Name (You)*

Principal's Address*

Agent's Full Legal Name*

Agent's Address*

Agent's Phone Number*

Successor Agent Full Name

Backup agent if primary agent cannot serve

Successor Agent Address

Powers Granted to Agent*

List the specific healthcare powers your agent may exercise

Limitations on Agent's Authority

Specify any treatments or decisions your agent is NOT authorized to make

End-of-Life Wishes

Describe your wishes regarding life support, artificial nutrition, pain management, and hospice care

Organ and Tissue Donation*

Execution Date*

MM/DD/YYYY

What Is a Healthcare Power of Attorney?

When Do You Need It?

Every adult over 18 should have a healthcare power of attorney as part of a basic estate plan. You especially need one if you are about to undergo surgery or a medical procedure, are diagnosed with a serious illness, are older or have chronic health conditions, or simply want to ensure that a trusted person can advocate for your medical wishes if you cannot speak for yourself. Without this document, healthcare decisions may be left to family members who may disagree, or to medical providers following default state law protocols..

What's Included in This Template

Principal and agent full names and contact information
Successor agent designation
Specific healthcare powers granted
Limitations on agent's authority
End-of-life wishes and instructions
Organ donation preferences
Execution date and signature block
Witness signature blocks
Notarization block

How to Fill It Out

Identify Your Principal and Agent — Enter your full legal name as the principal (the person granting authority). Then enter the name, address, and phone number of your agent — the trusted person who will make healthcare decisions on your behalf. Choose someone who knows your values and can handle emotionally difficult decisions.

Designate a Successor Agent — Name a backup agent who will serve if your primary agent is unable or unwilling to act. This ensures someone is always available to speak for you.

Specify the Powers Granted — Select which healthcare decisions your agent is authorized to make: consenting to treatment, hospital admission, medication, surgery, and/or hospice care. You may also grant broad general authority.

Add Limitations and End-of-Life Wishes — If there are specific treatments you would refuse or specific instructions for end-of-life care, enter them clearly. For example, you may specify whether you want life support continued under certain conditions.

Organ Donation Preference — Select your organ donation preference. If you are already registered as an organ donor in your state, note that this document serves as an additional expression of your wishes.

Execute the Document — Sign and date the document in the presence of two witnesses and a notary public. Most states require either witnesses, notarization, or both. Witnesses generally cannot be your agent, a healthcare provider, or a beneficiary under your will.

Legal Requirements & Notes

Healthcare powers of attorney are governed by state law and requirements vary significantly. Key considerations:

State-specific forms: Many states have statutory healthcare POA forms. While a non-statutory form is generally valid, some states (including California, New York, and North Carolina) have specific requirements for the language, witnesses, and notarization. Review your state's specific healthcare POA statute.

Witness requirements: Most states prohibit the designated agent, the principal's healthcare provider, and operators of healthcare facilities from serving as witnesses. Requirements vary — some states require two witnesses; others require notarization instead of or in addition to witnesses.

HIPAA authorization: A healthcare POA should include HIPAA authorization so your agent can access your medical records and communicate with healthcare providers. This form includes that authorization.

Relationship to living will: A healthcare POA designates who makes decisions; a living will (advance directive) states what your decisions are. Together they provide the most complete protection. See the Living Will template.

Revocation: A healthcare POA can be revoked at any time as long as the principal has capacity. Revocation should be communicated in writing to the agent and to healthcare providers.

Distribution: Give copies to your agent, successor agent, primary care physician, any specialists, and any hospital where you are likely to receive care. Keep the original in a secure but accessible location.

Frequently Asked Questions

A healthcare power of attorney designates a specific person (your agent) to make healthcare decisions for you if you are unable to do so. A living will (also called an advance directive) directly states your wishes about specific medical treatments — particularly end-of-life care. They work together: the healthcare POA gives your agent authority to act; the living will guides their decisions. It is strongly recommended to have both.

Free Healthcare Power of Attorney Template — Fill Out & Download Instantly

HEALTHCARE POWER OF ATTORNEY

NOTICE TO PRINCIPAL

DESIGNATION OF HEALTHCARE AGENT

HEALTHCARE AGENT (PRIMARY):

DURABILITY

HEALTHCARE DECISIONS — POWERS GRANTED

LIMITATIONS ON AGENT'S AUTHORITY

END-OF-LIFE INSTRUCTIONS

ORGAN AND TISSUE DONATION

EFFECT OF DEATH

REVOCATION

EXECUTION

STATEMENT OF WITNESSES

WITNESS 1:

WITNESS 2:

NOTARY ACKNOWLEDGMENT

[SEAL]

What Is a Healthcare Power of Attorney?

When Do You Need It?

What's Included in This Template

How to Fill It Out

Legal Requirements & Notes

Frequently Asked Questions

Related Templates

Durable Power of Attorney

Living Will (Advance Directive)

Last Will & Testament