Ohio Medical Power of Attorney Template
This document serves as a Medical Power of Attorney in accordance with Ohio state law. It allows you to designate a trusted individual to make healthcare decisions on your behalf if you become unable to do so.
Principal Information:
- Name: ______________________________
-
- City: ________________________________
- State: Ohio
- Zip Code: ___________________________
- Date of Birth: ______________________
Agent Information:
- Name: ______________________________
- Address: ____________________________
- City: ________________________________
- State: ______________________________
- Zip Code: ___________________________
- Phone Number: ______________________
Durability of Power of Attorney:
This Medical Power of Attorney shall remain in effect even if I become incapacitated.
Healthcare Decisions:
I grant my Agent the authority to make decisions regarding my medical treatment, including but not limited to:
- Choosing healthcare providers
- Consenting to or refusing medical treatment
- Accessing my medical records
- Making decisions about life-sustaining treatment
Signatures:
By signing below, I confirm that I am of sound mind and that I understand the contents of this document.
_______________________________
Signature of Principal
Date: _________________________
_______________________________
Signature of Agent
Date: _________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to the Principal or the Agent.
Witness 1: ____________________________
Signature: ____________________________
Date: _________________________________
Witness 2: ____________________________
Signature: ____________________________
Date: _________________________________
Notary Acknowledgment:
State of Ohio
County of ____________________________
Subscribed and sworn before me this _____ day of ____________, 20__.
_______________________________
Notary Public
My commission expires: _______________