Hawaii Medical Power of Attorney Template
This Medical Power of Attorney allows you to designate someone to make medical decisions on your behalf in Hawaii. This document is governed by Hawaii Revised Statutes, Chapter 327E.
Principal Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: _____________________
- Date of Birth: ________________________
Agent Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: _____________________
- Phone Number: ________________________
Effective Date:
This Medical Power of Attorney becomes effective when I am unable to make my own medical decisions.
Agent's Authority:
I grant my agent the authority to make any and all medical decisions on my behalf, including but not limited to:
- Decisions about medical treatments and procedures
- Choices regarding healthcare providers
- Access to my medical records
Limitations:
Any limitations on the agent’s authority are as follows:
___________________________________________________________
___________________________________________________________
Signature:
By signing below, I confirm that I am of sound mind and voluntarily appoint the above-named agent to act on my behalf regarding medical decisions.
_____________________________
Signature of Principal
Date: ______________________
Witnesses:
This document must be witnessed by two individuals who are not related to the principal or the agent.
- Name: _______________________________
Signature: __________________________
Date: _______________________________
- Name: _______________________________
Signature: __________________________
Date: _______________________________
Notarization:
State of Hawaii, County of _______________
Subscribed and sworn to before me this _____ day of __________, 20__.
_____________________________
Notary Public
My Commission Expires: ________________