Healthcare Power of Attorney

Drafts a jurisdiction-compliant HCPOA that designates an agent, defines scope of authority, captures principal treatment directives, and satisfies state execution formalities.

Prerequisites

Principal — full legal name, address, DOB
Agent — full legal name, address, contact; confirm eligibility under state law (some states disqualify treating physicians, facility employees)
Successor agent(s) — same details if designated; activation sequence
Jurisdiction — governs statutory form, witness/notary rules, mandatory language
Healthcare preferences — wishes on life-sustaining treatment, ANH, CPR, palliative care, organ donation
Religious/moral directives or limitations on agent authority (if any)

Output Structure

1. Jurisdictional Research (pre-draft)

Complete before drafting:

| Requirement | Details | |---|---| | Statutory form required? | Yes / No — cite statute [VERIFY] | | Witness count & eligibility | Typically 2; confirm exclusions (agent, providers, relatives) | | Notarization | Required / Optional / Not required | | Mandatory warnings/notices | Include verbatim if required by statute | | Prohibited provisions | E.g., some states bar agent from refusing comfort care | | Duration / revocation | Durable by default in most states; confirm revocation methods |

2. Document Sections

TITLE: Healthcare Power of Attorney of [Principal Full Name] — State of [Jurisdiction]

ARTICLE 1 — DESIGNATION OF AGENT

Primary agent: name, address, relationship
Successor agent(s): same; activation sequence when primary is unavailable/unwilling

ARTICLE 2 — EFFECTIVE DATE AND DURABILITY

Springing (incapacity-triggered) vs. immediate authority
Durability language per state statute; incapacity determination standard

ARTICLE 3 — SCOPE OF AUTHORITY

Standard grant:

[ ] Medical treatment decisions (surgical, diagnostic, medication)
[ ] Facility placement and transfer
[ ] Hiring/discharging healthcare providers
[ ] Access to medical records (HIPAA release — see Article 6)
[ ] Organ/tissue donation and anatomical gifts
[ ] Disposition of remains (if principal elects)

Principal-specified limitations:

ARTICLE 4 — SPECIFIC HEALTHCARE DIRECTIVES

| Scenario | Terminal Condition | Persistent Vegetative State | |---|---|---| | Artificial nutrition & hydration | Withhold / Provide / Agent discretion | Withhold / Provide / Agent discretion | | Mechanical ventilation | Withhold / Provide / Agent discretion | Withhold / Provide / Agent discretion | | CPR | Withhold / Provide / Agent discretion | Withhold / Provide / Agent discretion | | Dialysis | Withhold / Provide / Agent discretion | Withhold / Provide / Agent discretion | | Pain management / palliative care | Principal directive | Principal directive |

Distinguish binding directives from guidance for agent discretion.

ARTICLE 5 — RELIGIOUS/MORAL GUIDANCE

Faith traditions or values to guide agent decision-making

ARTICLE 6 — HIPAA AUTHORIZATION

Explicit authorization for agent to access all PHI necessary to perform duties
Reference 45 C.F.R. § 164.510(b) [VERIFY current reg]
Effective immediately upon execution (not contingent on incapacity trigger)

ARTICLE 7 — REVOCATION

Principal may revoke orally, in writing, or by destruction
Later-executed document controls; notification instructions to agent and providers

ARTICLE 8 — SEVERABILITY AND GOVERNING LAW

ARTICLE 9 — CAPACITY DECLARATION

Principal affirms voluntary execution, without duress or undue influence, while of sound mind

3. Execution Block

PRINCIPAL SIGNATURE

_______________________________   Date: __________
[Principal Full Name]

WITNESS ATTESTATIONS (confirm count per jurisdiction)

We affirm the principal signed voluntarily, appears competent, and we are not the
designated agent, not related by blood/marriage, and not involved in the principal's healthcare.

Witness 1: _______________________________   Date: __________
Address: ________________________________

Witness 2: _______________________________   Date: __________
Address: ________________________________

NOTARIAL CERTIFICATE (if required by jurisdiction)

State of ___________, County of ___________
Subscribed and sworn before me on __________ by ______________________.

_______________________________
Notary Public — Commission Expires: __________

Guidelines

Verify statutory form — CA, NY, TX, FL and others have mandatory or model forms; use or adapt as required [VERIFY each state]
HIPAA gap — an HCPOA without explicit HIPAA language may be rejected by providers; always include Article 6
Co-agent conflicts — if co-agents appointed, specify joint vs. independent authority and deadlock resolution
Provider immunity — note state good-faith immunity provisions to aid provider acceptance
Organ donation — some states require a separate anatomical gift form; confirm whether HCPOA alone suffices [VERIFY]
Comfort care — do not include provisions barring palliative care where prohibited by state law
Distribution — recommend principal retain original; copies to agent, primary physician, and hospital of choice
Do not fabricate statutory citations or execution requirements; mark uncertain references [VERIFY]
Attorney review required — include disclaimer that document requires attorney review before execution