Michigan Medical Power of Attorney
This Medical Power of Attorney is designed to comply with Michigan state laws regarding healthcare decision-making. This document allows you to appoint someone 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: ___________________
Grant of Authority:
I hereby appoint the above-named agent to make medical decisions on my behalf. This authority includes the power to:
- Consent to or refuse medical treatment.
- Access my medical records.
- Make decisions regarding life-sustaining treatment.
Effective Date:
This Medical Power of Attorney becomes effective when I am unable to make my own healthcare decisions, as determined by my attending physician.
Revocation:
I retain the right to revoke this document at any time, provided I am of sound mind. To revoke, I must notify my agent and any healthcare providers involved in my care.
Signatures:
By signing below, I confirm that I understand the contents of this document and the authority I am granting to my agent.
_____________________________
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: ______________________
- Witness 2: ______________________
Date: ________________________