Medical Power of Attorney Authorization
Name of Principal:
Address of Principal:
Date of Birth:
Designation of Agent
Name of Agent:
Address of Agent:
Phone Number of Agent:
Alternate Agent (Optional)
Name of Alternate Agent:
Address of Alternate Agent:
Phone Number of Alternate Agent:
Grant of Authority
Limitations and special instructions regarding the agent’s authority:
Effective Date and Duration
Effective Date:
Expiration Date (or "None"):
Additional Instructions or Statements:
Principal’s Signature:
Date:
Witness Signature:
Date: