Healthcare Power of Attorney Template, Free Download 2026

[NOTE TO PREPARER: many states publish a statutory health care power of attorney or advance directive form, and some require specific warnings, a particular number of witnesses, witnesses with particular qualifications (for example, not the agent, not a relative, not an heir, not a health care provider), or notarization. If the state where this will be signed has a statutory form, consider using it, or confirm this document meets every requirement of the statute. Delete this note before signing.]

I, [____________] ("Principal"), of [address: ____________], appoint [____________], of [address: ____________], telephone [____________], email [____________], as my health care agent ("Agent") to make health care decisions for me as authorized in this document. This document is made under the law of the State of [____________].

If my Agent is not willing, able, or reasonably available to act, I appoint, in this order: First Alternate Agent: [name, address, telephone: ____________]; Second Alternate Agent: [name, address, telephone: ____________]. An alternate agent has the same authority as my Agent. [If I name my spouse or partner as Agent, that appointment ends if we divorce, our marriage is annulled, or we legally separate, unless I state otherwise here: ____________.]

My Agent's authority begins [when my attending physician (and, if state law requires, a second physician or other qualified professional) determines that I lack the capacity to make my own health care decisions / immediately, but while I have capacity my own decisions control over my Agent's]. My Agent's authority ends if I regain capacity and resumes if I lose it again. This power of attorney is not affected by my later disability or incapacity.

My Agent may make any health care decision I could make if I had capacity, including to: consent to, refuse, or withdraw consent to any care, treatment, service, test, or procedure; choose and discharge health care providers and facilities; approve admission to or discharge from any hospital, nursing home, assisted living facility, or hospice; obtain, review, and authorize release of my medical records; and sign any waiver, release, or other document needed to carry out these decisions.

My Agent shall decide according to my instructions in this document and my other wishes to the extent my Agent knows them. Where my wishes are not known, my Agent shall decide according to my Agent's good-faith judgment of my best interest, considering my personal values.

Initial ONE choice: [____] I want my life prolonged as long as possible within the limits of generally accepted health care standards. [____] I do not want my life prolonged if (a) I have an incurable and irreversible condition that will result in my death within a relatively short time, (b) I become unconscious and, to a reasonable degree of medical certainty, will not regain consciousness, or (c) the likely risks and burdens of treatment would outweigh the expected benefits. [____] My Agent decides, considering my values and these instructions.

Artificial nutrition and hydration (tube feeding). Initial ONE choice: [____] Follow my choice above. [____] Provide it in all cases. [____] Do not provide it if I am in a condition described in (a) or (b) above. [NOTE TO PREPARER: some states require the principal to state a choice about artificial nutrition and hydration specifically, or the agent cannot refuse it. Delete this note before signing.]

Relief from pain and discomfort: I want treatment for pain and discomfort at all times, even if it hastens my death [____ initial] / [other instructions: ____________].

My Agent may NOT: [consent to my admission to a mental health facility for more than ______ days without a court order / consent to electroconvulsive therapy or psychosurgery / other: ____________]. [Religious or personal instructions: ____________.] [NOTE TO PREPARER: many states bar any agent from consenting to certain treatments, such as psychosurgery, sterilization, or involuntary mental health commitment, no matter what this document says. Delete this note before signing.]

Initial ONE choice: [____] I make no anatomical gift. [____] On my death I give [any needed organs, tissues, or parts / only the following: ____________] for [transplantation / therapy / research / education / all of these purposes]. [____] My Agent may decide. To the extent state law allows, my Agent may also authorize an autopsy and direct the disposition of my remains [according to these instructions: ____________].

If a court needs to appoint a guardian of my person, I nominate [my Agent, in the order named above / ____________].

While my Agent has authority to make health care decisions for me, my Agent is my personal representative under the HIPAA Privacy Rule (45 C.F.R. Section 164.502(g)), and my health care providers and health plans shall treat my Agent as they would treat me for access to and disclosure of my protected health information relevant to those decisions. If I want my Agent to obtain my health information before that authority begins (for example, to obtain the physician determination described above), I will sign a separate HIPAA authorization containing the elements required by 45 C.F.R. Section 164.508(c).

My Agent serves [without compensation, but with reimbursement of reasonable expenses / with reasonable compensation and reimbursement of reasonable expenses]. To the extent state law allows, a health care provider who relies in good faith on a decision of my Agent is not liable to me or my estate for complying with it.

I may revoke this document, or my Agent's appointment, in any manner state law allows, including by a signed writing or by telling my supervising health care provider. A later health care power of attorney revokes this one to the extent they conflict. This document revokes any earlier health care power of attorney I have signed. A copy, including an electronic copy, is as valid as the original.

I sign this document voluntarily, I understand its purpose and effect, and I have the capacity to make it. Neither my Agent nor any alternate agent signs as a witness.