Michigan Medical Power of Attorney Template
This Medical Power of Attorney is designed specifically for residents of Michigan. It allows you to appoint someone to make healthcare decisions on your behalf in case you become unable to do so yourself. This document is governed by Michigan law, specifically the Michigan Estates and Protected Individuals Code (EPIC).
Principal Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip Code: ________________
- Date of Birth: ________________________
Agent Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip Code: ________________
- Phone Number: ______________________
Statement of Authority:
I, the undersigned, hereby appoint the above-named Agent as my Medical Power of Attorney. My Agent shall have the authority to make healthcare decisions on my behalf, including but not limited to:
- Consent to or refuse medical treatment.
- Access my medical records and information.
- Make decisions regarding life-sustaining treatment.
Limitations:
Any limitations on the authority of my Agent should be specified here:
____________________________________________________________________
____________________________________________________________________
Effective Date:
This Medical Power of Attorney shall become effective immediately upon my incapacity or inability to make my own healthcare decisions.
Signature:
By signing below, I confirm that I am of sound mind and that I understand the nature and effect of this document.
Signature of Principal: ___________________________
Date: ___________________________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to you or your Agent.
Witness 1: ______________________________________
Date: ___________________________________________
Witness 2: ______________________________________
Date: ___________________________________________
Notarization:
State of Michigan, County of _______________
Subscribed and sworn before me this _____ day of ____________, 20__.
Notary Public: __________________________________
My Commission Expires: _________________________