Colorado Medical Power of Attorney
This Colorado Medical Power of Attorney is governed by the laws of the State of Colorado. It creates a durable power of attorney for healthcare, allowing a designated agent to make medical decisions on behalf of the principal in the event the principal is unable to make such decisions.
Principal Information
Name: ___________________________________________________________
Address: _________________________________________________________
City, State, Zip: __________________________________________________
Phone Number: _____________________________________________________
Email Address: ____________________________________________________
Agent Information
Name: ___________________________________________________________
Address: _________________________________________________________
City, State, Zip: __________________________________________________
Phone Number: _____________________________________________________
Email Address: ____________________________________________________
Alternate Agent Information (Optional)
Name: ___________________________________________________________
Address: _________________________________________________________
City, State, Zip: __________________________________________________
Phone Number: _____________________________________________________
Email Address: ____________________________________________________
By signing this document, the principal appoints the designated agent to make healthcare decisions on the principal's behalf, should the principal become unable to make those decisions. The power granted by this document includes, but is not limited to, the authority to consent, refuse, or withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
This power of attorney becomes effective immediately upon the incapacity of the principal, as determined by a physician. In the event that the primary agent is unable or unwilling to serve, the alternate agent (if designated) shall serve.
Signature and Acknowledgment
Principal's Signature: _______________________________ Date: _______________
Agent's Signature: __________________________________ Date: _______________
Alternate Agent's Signature (Optional): _________________ Date: _______________
This document was signed in the presence of two witnesses, as required by Colorado law. The witnesses cannot be the agent, the alternate agent, a family member, heir, or any individual entitled to any part of the principal’s estate upon death.
Witnesses
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Name: __________________________________________
Signature: ______________________________________ Date: _______________
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Name: __________________________________________
Signature: ______________________________________ Date: _______________
This Medical Power of Attorney should be provided to both the agent and any alternate agent named, as well as the principal's health care providers.