North Carolina Medical Power of Attorney
This Medical Power of Attorney ("Document") is created in accordance with the North Carolina Health Care Power of Attorney Act (N.C. Gen. Stat. § 32A-15 to 32A-26). It grants authority to a designated person to make health care decisions on the principal's behalf when the principal is unable to make or communicate decisions for themselves.
Please fill in the blanks with the appropriate information to complete this document:
Principal's Information
- Full Name: ___________________________
- Address: _____________________________
- City, State, ZIP: ______________________
- Date of Birth: ________________________
- Social Security Number: _______________
Health Care Agent's Information
- Full Name: ___________________________
- Address: _____________________________
- City, State, ZIP: ______________________
- Primary Phone Number: _________________
- Alternate Phone Number: _______________
Alternate Health Care Agent's Information (Optional)
- Full Name: ___________________________
Address: _____________________________
- City, State, ZIP: ______________________
- Primary Phone Number: _________________
- Alternate Phone Number: _______________
In the event that my primary Health Care Agent is unable, unwilling, or unavailable to act as my agent, I designate the above-named Alternate Health Care Agent to make health care decisions on my behalf.
Special Instructions: (Here, you may include any specific wishes, limitations, or special instructions for your Health Care Agent.)
Signature and Acknowledgement
This document does not take effect unless the principal is unable to make or communicate health care decisions. The principal may revoke this document at any time and in any manner sufficient to communicate an intent to revoke.
Principal's Signature: _____________________ Date: ____________
State of North Carolina, County of _______________
This document was acknowledged before me on (date) _____________ by (name of principal) ____________________________.
________________________________
Signature of Notary Public
My commission expires: ____________
Witnesses:
- Witness Full Name: _______________________
Signature: ______________________ Date: ________
- Witness Full AMe: _______________________
Signature: ______________________ Date: ________
Note: Two competent witnesses are required for this document to be legally binding. Witnesses should not be the health care agent, the principal’s spouse, heirs, or healthcare providers.