North Carolina Medical Power of Attorney
This Medical Power of Attorney is a legal document that appoints someone, known as an "Agent," to make medical decisions on behalf of the "Principal" should the Principal become unable to make decisions for themselves. This document is specifically created in accordance with the North Carolina Health Care Power of Attorney Act, which is unique to the state of North Carolina.
Please fill out all the following information accurately.
Principal's Information:
- Full Name: ___________________________
- Address: ____________________________
- City: _______________________________
- State: North Carolina
- ZIP Code: ___________________________
- Date of Birth: ______________________
Agent's Information:
- Full Name: ___________________________
- Address: ____________________________
- City: _______________________________
- State: _____________________________
- ZIP Code: ___________________________
- Primary Phone: ______________________
- Alternate Phone: ____________________
In accordance with North Carolina law, the Principal appoints the above-named Agent to make health care decisions on their behalf under circumstances where they are deemed unable to make such decisions for themselves. This authority includes, but is not limited to, decisions regarding the selection and dismissal of health care providers, approval or refusal of diagnostic tests, surgical procedures, medication plans, and end-of-life care.
The Principal has the right to revoke this power of attorney at any time when they are mentally competent to do so, through a written notice to the Agent.
This document will become effective upon the signature of the Principal and will remain in effect until it is revoked.
Signature:
By signing below, the Principal acknowledges that they understand the nature and purpose of this document and the powers it grants to the Agent.
- Principal's Signature: _______________________________ Date: ______________
- Agent's Signature: _________________________________ Date: ______________
This document must also be signed by two witnesses, who attest that the Principal is of sound mind, acting of free will, and under no duress or undue influence.
Witnesses:
- Name: ____________________________________ Signature: ________________________ Date: _______________
- Name: ____________________________________ Signature: ________________________ Date: _______________
Notarization (If required by North Carolina law or at the Principal's discretion):
This document was acknowledged before me on this date: ________________
- Notary's Signature: ___________________________________
- Notary's Printed Name: _______________________________
- Date Commission Expires: _____________________________