Washington Medical Power of Attorney
This Washington Medical Power of Attorney is a legal document that grants an individual (hereinafter referred to as the "Principal") the ability to designate a trusted individual (hereinafter referred to as the "Agent") to make healthcare decisions on the Principal's behalf in the event the Principal is unable to communicate such decisions themselves. It is in accordance with the relevant sections of the Washington Uniform Power of Attorney Act.
Principal Information:
- Full Name: ___________________________
- Date of Birth: ___________________________
- Address: ___________________________
- Contact Number: ___________________________
Agent Information:
- Full Name: ___________________________
- Relationship to Principal: ___________________________
- Address: ___________________________
- Alternate Contact Number: ___________________________
Alternate Agent Information (Optional):
- Full Name: ___________________________
- Relationship to Principal: ___________________________
- Address: ___________________________
- Contact Number: ___________________________
In the event the initial Agent is unable, unwilling, or unavailable to act as the Principal's Agent, the Alternate Agent will assume the powers and responsibilities outlined in this document.
This power of attorney becomes effective upon the occurrence of the Principal becoming unable to make their own healthcare decisions, as verified by a licensed physician.
The Powers granted to the Agent include, but are not limited to, the following:
- Consent to or reject any medical treatment, surgery, or procedure.
- Access to the Principal's medical records necessary for making informed decisions about the Principal's health care.
- Decide on the Principal's admission to or discharge from any hospital, hospice, or long-term care facility.
- Authorize the donation of the Principal's organs for medical research or transplantation, if the Principal has not expressed contrary wishes.
This Medical Power of Attorney is subject to any statements or limitations provided herein:
______________________________________________________________________________
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Signature of Principal: ___________________________ Date: _________________
Signature of Agent: ___________________________ Date: _________________
Signature of Alternate Agent (Optional): ___________________________ Date: _________________
This document must be signed in the presence of two witnesses, who are not the Agent, Alternate Agent, healthcare provider, or relative by blood or marriage of the Principal. Additionally, it must be notarized to be valid and legally binding.
Witness 1 Signature: ___________________________ Date: _________________
Witness 2 Signature: ___________________________ Date: _________________
Notary Public Signature: ___________________________ Date: _________________
This document is not a Durable Power of Attorney for healthcare decisions unless it expressly includes the term "Durable" in its title or body.