Blank Medical Power of Attorney Form for Michigan State

Michigan Medical Power of Attorney

This Michigan Medical Power of Attorney is a legal document that allows an individual, known as the Principal, to designate another person, referred to as the Agent, to make healthcare decisions on their behalf should they become unable to do so. This document is governed by the laws of the State of Michigan, specifically the Michigan Durable Power of Attorney for Health Care Act.

Principal's Information:

• Full Name: ________________________________________
• Address: __________________________________________
• City, State, Zip: ___________________________________
• Phone Number: _____________________________________

Agent's Information:

• Full Name: ________________________________________
• Address: __________________________________________
• City, State, Zip: ___________________________________
• Phone Number: _____________________________________

In the event that the first Agent is unable or unwilling to serve, an Alternate Agent may be designated:

• Full Name: ________________________________________
• Address: __________________________________________
• City, State, Zip: ___________________________________
• Phone Number: _____________________________________

By signing this document, the Principal grants the Agent the authority to make all healthcare decisions on their behalf, in accordance with the preferences and directives stated herein, when the Principal is determined to be unable to make healthcare decisions for themselves. The Agent's authority includes, but is not limited to, the following:

1. Deciding on the start, continuation, and cessation of medical treatments and procedures.
2. Selecting or discharging healthcare providers and institutions.
3. Having access to medical records and the authority to disclose them as necessary.

This Michigan Medical Power of Attorney becomes effective immediately upon the Principal's incapacity to make healthcare decisions, as determined by attending physician or court of competent jurisdiction. It remains in effect until revoked or upon the death of the Principal.

The Principal has the right to revoke this document at any time, provided they are competent to do so.

Signature of Principal: _________________________________ Date: ___________

Signature of Agent: ___________________________________ Date: ___________

Witness Declaration:

I, __________________________________ (Print Name), declare that the Principal appears to be of sound mind and free from duress at the time of signing this Michigan Medical Power of Attorney, and they acknowledge that they are aware of the nature of this document and sign it freely and voluntarily.

Signature of Witness #1: _______________________________ Date: ___________

Signature of Witness #2: _______________________________ Date: ___________

This document was prepared on the date written above and is executed as a declarative statement of the Principal’s wishes regarding their healthcare decisions.