Durable Healthcare Power of Attorney

This durable Healthcare Power of Attorney form lets you name someone as your agent to make healthcare decisions for you if you are very sick or hurt.

You can cancel this Power of Attorney at any time—simply tell your doctors and family that you revoke your Healthcare Power of Attorney. Ask to have all copies of the form returned to you and destroy them.

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After You Finish

Learn what to do when you have finished filling out this form.
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After you download and fill out this form, follow these steps:

  • Carefully read and review the form. If leaving any sections blank, write “None” in that space or cross out the entire section.
  • Cross out any items on page 4 that you don’t want your agent to be able to decide.
  • Sign the form. You must either sign the form in front of two witness who fill out the witness statement on page 9, or sign the form in front of a notary public.
  • Make copies. After the form is signed, make several photocopies.
  • Share copies of the form. Give a copy of the form to your agent, your doctor and the hospital you are likely to be admitted to. Anytime you go to the hospital, bring a copy of the form with you.
  • Talk with your loved ones. It is helpful to share that you have a durable healthcare power of attorney with your loved ones. That way, they know who your agent is in case of an emergency.

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