Michigan Medical Power of Attorney
This document is intended to create a Michigan Medical Power of Attorney in accordance with Michigan state laws.
Principal Information:
Name: _________________________________
Address: _______________________________
City, State, Zip: ________________________
Date of Birth: __________________________
Agent Information:
Name: _________________________________
Address: _______________________________
City, State, Zip: ________________________
Phone: _________________________________
Designation of Agent:
I, the undersigned, hereby appoint the individual named above as my agent to make medical decisions on my behalf in accordance with Michigan law.
General Statement of Authority Granted:
This agent shall have the authority to make any and all healthcare decisions for me, including:
- Consent to or refuse any medical treatment.
- Access my medical records.
- Make decisions regarding organ donation.
- Transfer me to another healthcare facility.
Limitations on Agent’s Authority:
If there are any limitations to the powers granted to my agent, please specify them:
_________________________________________________________
_________________________________________________________
Effective Date:
This Medical Power of Attorney becomes effective immediately upon signing unless otherwise stated:
_________________________________________________________
Signature:
Principal’s Signature: _________________________
Date: _______________
Witnesses:
By signing below, we certify that the principal is of sound mind and voluntarily signed this document.
- Witness 1 Name: _____________________
- Witness 1 Signature: __________________
- Date: _______________
- Witness 2 Name: _____________________
- Witness 2 Signature: __________________
- Date: _______________