Delaware Medical Power of Attorney Template
This Medical Power of Attorney is created in accordance with Delaware law and allows you to designate a person to make medical decisions on your behalf if you become unable to do so.
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 shall become effective upon my incapacity as determined by a qualified healthcare provider.
Agent Authority:
I grant my agent 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.
- Choose healthcare providers and facilities.
Limitations: My agent's authority is limited as follows:
__________________________________________________________________________
__________________________________________________________________________
Revocation: I understand that I may revoke this Medical Power of Attorney at any time while I am still competent.
Signatures:
In witness whereof, I have signed this Medical Power of Attorney on this _____ day of __________, 20__.
___________________________
Signature of Principal
Witness Information:
- Name: __________________________
- Address: ________________________
- Signature: ______________________
Notary Public:
State of Delaware
County of _______________
Subscribed, sworn to, and acknowledged before me this _____ day of __________, 20__.
___________________________
Notary Public Signature
My Commission Expires: ______________