This document grants power of attorney for medical decisions in the state of Hawaii, pursuant to the Hawaii Revised Statutes §327E. Pursuant to this statute, an individual (hereinafter referred to as the "Principal") can appoint another person (referred to as the "Agent") to make healthcare decisions on their behalf should they become unable to do so.
Hawaii Medical Power of Attorney
Date: ________
I, _________________ (Full Name of Principal), residing at ___________________________ (Address of Principal), appoint ____________________ (Full Name of Agent), residing at _____________________________ (Address of Agent), as my Agent to make health care decisions on my behalf as authorized in this document.
The Agent's authority becomes effective when my attending physician certifies in writing that I lack the capacity to make or communicate health care decisions.
The powers granted to my Agent include, but are not limited to, the following:
- Choosing my health care providers.
- Approving or refusing medical tests, surgeries, or treatments.
- Deciding on my living arrangements for health care purposes.
- Accessing my medical records.
- Making decisions about withdrawing or withholding life-sustaining treatment.
These powers are subject to any statements or limitations provided below:
_________________________________________________________________________________
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This Medical Power of Attorney does not authorize my Agent to make financial decisions on my behalf.
This document revokes any prior Medical Power of Attorney granted by me. However, this does not affect the financial power of attorney documents I have in place.
In the event my primary Agent is unwilling or unable to perform, I designate ______________________ (Full Name of Alternate Agent) as alternate Agent, with all the same powers.
Signature of Principal: ___________________________________ Date: ________
This document was signed in the presence of two witnesses, neither of whom is the Agent or the alternate. The witnesses are not related to me by blood, marriage, or adoption, and they are not entitled to any part of my estate upon my death under a will or by operation of law.
Witness 1 Signature: ___________________________________ Date: ________
Print Name: ___________________________________
Witness 2 Signature: ___________________________________ Date: ________
Print Name: ___________________________________
State of Hawaii
County of _______________________
Subscribed, sworn to, or affirmed before me on this day, ___________, by ______________________ (name of Principal) and the above-named witnesses, proving to me through the presentation of valid identification.
Notary Signature: ___________________________________ Date: ________
My commission expires: _______________