North Dakota Medical Power of Attorney
This Medical Power of Attorney is a legal document that grants a person you choose the authority to make health care decisions on your behalf, should you become unable to make them yourself. This document is governed by the North Dakota Century Code Chapter 23-06.5, known as the Uniform Health-Care Decisions Act.
Principal Information:
- Full Name: ___________________________________________________
- Address: _____________________________________________________
- City, State, Zip: _____________________________________________
- Date of Birth: ________________________________________________
- Phone Number: _______________________________________________
Health Care Agent Information:
- Full Name: ___________________________________________________
- Relationship to Principal: _____________________________________
- Address: _____________________________________________________
- City, State, Zip: _____________________________________________
- Primary Phone Number: ________________________________________
- Alternate Phone Number: ______________________________________
In accordance with North Dakota law, I hereby designate the above-named individual as my attorney-in-fact (health care agent) to make health-related decisions for me as specified in this document, effective upon my incapacity to make informed health care decisions. My health care agent has the authority to make all decisions regarding my health care, including decisions regarding seeking, receiving, and reviewing my medical records, consenting or refusing any diagnostic, therapeutic, surgical procedures, and arranging for my care and treatment. This authority does not extend to the point of violating any directives I have made known, particularly those related to life-sustaining treatment unless specified otherwise in this document.
Special Instructions:
Any specific limitations to the agent's decision-making authority or specific desires related to health care, including preferences about treatments such as life-sustaining measures, should be listed here:
________________________________________________________________
________________________________________________________________
Signature of Principal: _______________________________ Date: ________________
Signature of Health Care Agent: _______________________ Date: ________________
Witness Declaration:
I declare that the principal appears to be of sound mind and under no duress, fraud, or undue influence. I am not the appointed health care agent or the principal's health care provider. I am not an employee of the principal’s health care provider, nor of any health care facility in which the principal is a patient. I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the principal’s estate upon their death under a will now existing or by operation of law.
Signature of Witness #1: _______________________________ Date: ________________
Signature of Witness #2: _______________________________ Date: ________________