Arkansas Medical Power of Attorney
This Medical Power of Attorney is executed in accordance with the laws of the State of Arkansas. It allows you to designate someone to make medical decisions on your behalf if you are unable to do so.
Principal Information:
Name: ___________________________________
Address: _________________________________
City, State, Zip: _________________________
Date of Birth: ____________________________
Agent Information:
Name: ___________________________________
Address: _________________________________
City, State, Zip: _________________________
Phone Number: ___________________________
Durability of Power of Attorney:
This Medical Power of Attorney is durable and will remain in effect until revoked by the Principal.
Effective Date:
This document becomes effective when the Principal is unable to make their own medical decisions as determined by a qualified healthcare provider.
Agent's Authority:
The Agent shall have the authority to make any and all medical decisions on behalf of the Principal, including but not limited to:
- Choosing healthcare providers.
- Consenting to or refusing medical treatment.
- Accessing medical records.
- Making decisions about life-sustaining treatments.
Signatures:
Principal's Signature: ___________________________
Date: _________________________________________
Witness Signature: _____________________________
Date: _________________________________________
Notary Acknowledgment:
State of Arkansas
County of _________________________________
Subscribed and sworn before me this _____ day of __________, 20__.
Notary Public: ______________________________
My Commission Expires: _____________________