North Carolina Medical Power of Attorney
This Medical Power of Attorney is a legal document that grants an individual (herein referred to as the "Agent") the power to make healthcare decisions on behalf of the undersigned (herein referred to as the "Principal"), in accordance with the North Carolina Health Care Power of Attorney Act (N.C. Gen. Stat. § 32A-15 to 32A-26).
Principal Information:
- Full Name: ___________________________
- Address: _____________________________
- City: ________________________________
- State: North Carolina
- Zip Code: ____________________________
- Date of Birth: ________________________
- Social Security Number: _______________
Agent Information:
- Full Name: ___________________________
- Address: _____________________________
- City: ________________________________
- State: _______________________________
- Zip Code: ____________________________
- Relationship to Principal: ____________
- Primary Phone: ________________________
- Alternate Phone: ______________________
This document does not authorize the Agent to make any financial decisions on behalf of the Principal.
Directions for Health Care:
The Principal directs the Agent to make health care decisions in keeping with the Principal's individual wishes, religious and moral beliefs. If the Principal's wishes are not known, the Agent has the discretion to make decisions as they deem fit, considering the best interests of the Principal.
Effective Date and Duration:
This Power of Attorney shall become effective upon the incapacity of the Principal and will continue in effect until the Principal's death, unless revoked earlier by the Principal in a written document.
Signatures:
- Principal's Signature: __________________________ Date: _________
- Agent's Signature: _____________________________ Date: _________
- Witness 1 Signature: ___________________________ Date: _________
- Witness 2 Signature: ___________________________ Date: _________
Notarization:
This document was acknowledged before me on (date) ______________ by (name of Principal) ______________________.
Notary Public: ____________________________
My commission expires: ____________________
This document is executed as a deed and is intended to be legally binding. The Principal affirms that they are of sound mind and under no duress or undue influence at the time of execution of this document.
Important Notice:
Both the Principal and Agent are encouraged to review the laws governing Medical Powers of Attorney in North Carolina to fully understand the scope and implications of this document.