Alabama Medical Power of Attorney
This Medical Power of Attorney is made in accordance with the Alabama Durable Power of Attorney for Health Care Act. It allows you, the Principal, to designate a trusted person as your Agent to make health care decisions on your behalf should you become unable to make them for yourself.
Principal Information
Name: ___________________________________________
Address: ________________________________________
City, State, Zip: ________________________________
Date of Birth: ___________________________________
Social Security Number: _________________________
Agent Information
Name: ___________________________________________
Relationship to Principal: ________________________
Address: ________________________________________
City, State, Zip: ________________________________
Primary Phone: __________________________________
Alternate Phone: ________________________________
Alternate Agent Information (In case primary Agent is unable or unwilling to serve)
Name: ___________________________________________
Relationship to Principal: ________________________
Address: ________________________________________
City, State, Zip: ________________________________
Primary Phone: __________________________________
Alternate Phone: ________________________________
By signing this document, you authorize your Agent to make any and all health care decisions for you, except to the extent you state otherwise. This authority includes, but is not limited to, consent or refusal of medical treatment, access to medical records, and decisions about withdrawing or withholding life-sustaining treatment.
You can also indicate your specific wishes regarding any treatment preferences below:
Treatment Preferences:
_________________________________________________________
_________________________________________________________
_________________________________________________________
This Medical Power of Attorney becomes effective when I am unable to make my own health care decisions as certified by a physician. It will remain in effect until I revoke it or it is terminated upon my death, except as to decisions made prior to my death or revocation.
Signature of Principal
Date: __________________ Signature: ___________________________
Witness Statement
We declare that the Principal appears to be of sound mind and free from duress at the time this document was signed, and that he/she signed it in our presence.
Witness 1
Name: ___________________________________________
Date: __________________ Signature: ___________________________
Witness 2
Name: ___________________________________________
Date: __________________ Signature: ___________________________
Please note, the laws regarding medical power of attorney vary from state to state. It is recommended to consult a legal professional to ensure this document meets all legal requirements in Alabama.