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INFORMATION ABOUT THIS DOCUMENT
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT IT IS VITAL FOR YOU TO KNOW AND UNDERSTAND THESE FACTS:
THIS DOCUMENT GIVES THE PERSON YOU NAME AS YOUR ATTORNEY-IN-FACT THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU CANNOT MAKE THE DECISIONS FOR YOURSELF.
AFTER YOU HAVE SIGNED THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE HEALTH CARE DECISIONS FOR YOURSELF IF YOU ARE MENTALLY COMPETENT TO DO SO. IN ADDITION, AFTER YOU HAVE SIGNED THIS DOCUMENT, NO TREATMENT MAY BE GIVEN TO YOU OR STOPPED OVER YOUR OBJECTION IF YOU ARE MENTALLY COMPETENT TO MAKE THAT DECISION.
YOU MAY STATE IN THIS DOCUMENT ANY TYPE OF TREATMENT THAT YOU DO NOT DESIRE AND ANY THAT YOU WANT TO MAKE SURE YOU RECEIVE.
YOU HAVE THE RIGHT TO TAKE AWAY THE AUTHORITY OF YOUR ATTORNEY-IN-FACT UNLESS YOU HAVE BEEN ADJUDICATED INCOMPETENT, BY NOTIFYING YOUR ATTORNEY-IN-FACT OR HEALTH CARE PROVIDER EITHER ORALLY OR IN WRITING. SHOULD YOU REVOKE THE AUTHORITY OF YOUR ATTORNEY-IN-FACT, IT IS ADVISABLE TO REVOKE IN WRITING AND TO PLACE COPIES OF THE REVOCATION WHEREVER THIS DOCUMENT IS LOCATED.
IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A SOCIAL WORKER, LAWYER, OR OTHER PERSON TO EXPLAIN IT TO YOU.
YOU SHOULD KEEP A COPY OF THIS DOCUMENT AFTER YOU HAVE SIGNED IT. GIVE A COPY TO THE PERSON YOU NAME AS YOUR ATTORNEY-IN-FACT. IF YOU ARE IN A HEALTH CARE FACILITY, A COPY OF THIS DOCUMENT SHOULD BE INCLUDED IN YOUR MEDICAL RECORD.
POWER OF ATTORNEY FOR HEALTH CARE
. DESIGNATION OF HEALTH CARE ATTORNEY-IN-FACT. I, , of the District of Columbia, hereby appoint (Your health care provider may not be named as the Attorney-in-Fact.):
| Attorney-in-Fact: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
as my Attorney-in-Fact (Agent) to make health care decisions for me if I become unable to make my own health care decisions. This gives my Attorney-in-Fact the power to grant, refuse, or withdraw consent on my behalf for any health care service, treatment or procedure. My Attorney-in-Fact also has the authority to talk to health care personnel, get information and sign forms necessary to carry out these decisions.
. CREATION OF POWER OF ATTORNEY FOR HEALTH CARE. With this document, I intend to create a Power of Attorney for Health Care, which shall take effect if I become incapable of making my own health care decisions and shall continue during that incapacity.
. RIGHTS AND DUTIES OF ATTORNEY-IN-FACT. Subject to any express limitations in this document, my Attorney-in-Fact shall have all the rights, powers and authority related to health care decisions that I would have under District and federal law, the authority to direct the withdrawal and withholding of artificially provided food and fluids. This authority shall include, at a minimum:
(a) The authority to grant, refuse or withdraw consent to the provision of any health care service, treatment or procedure;
(b) The right to review my health care records;
(c) The right to be provided with all information necessary to make informed health care decisions;
(d) The authority to select and discharge health care professionals; and
(e) The authority to make decisions regarding admission to or discharge from health care facilities and to take any lawful actions that may be necessary to carry out these decisions.
My Attorney-in-Fact shall make health care decisions as I direct below or as I make known to my Attorney-in-Fact in some other way.
SECOND ALTERNATE ATTORNEY-IN-FACT
| Attorney-in-Fact: |
| Address: |
| , |
| Phone: | Home: Work: |
. GENERAL PROVISIONS.
1. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
2. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
3. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
BY MY SIGNATURE I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF THIS DOCUMENT.
I sign my name to this form on the _____ day of ____________________, _____, in the District of Columbia.
| Signature: | ________________________________________ |
| Name: |
STATEMENT OF WITNESSES
I declare that , who signed or acknowledged this document, is personally known to me, that signed or acknowledged this Power of Attorney for Health Care in my presence, and that appears to be of sound mind, and under no duress, fraud or undue influence. I am not the person appointed as the Attorney-in-Fact by this document, nor am I the health care provider of or an employee of the health care provider of .
| Witness Signature: | ________________________________________ |
Date: _________________________
| Witness Signature: | ________________________________________ |
Date: _________________________
(AT LEAST 1 OF THE WITNESSES LISTED ABOVE SHALL ALSO SIGN THE FOLLOWING DECLARATION.)
I further declare that I am not related to by blood, marriage or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of under a currently existing will or by operation of law.
Signature: ________________________________________
Signature: ________________________________________
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It is quick and easy to grant or obtain the support you need with a free District of Columbia Medical Power of Attorney template from Rocket Lawyer:
This route is often notably more affordable and convenient than meeting and hiring a traditional attorney. If necessary, you may fill out this Medical PoA on behalf of an elderly parent, a spouse, or another family member, and then have them sign when ready. Please remember that for a Power of Attorney to be legally valid, the principal must be mentally competent when they sign. If the principal has already been declared incompetent, a court-appointed conservatorship may be necessary. In such a scenario, it's a good idea to work with a lawyer .
Every person over 18 ought to have a Medical Power of Attorney. Although it may be unpleasant to think about, a time may come when you can no longer make your own medical decisions. Common circumstances in which power of attorney can be helpful include:
Whether this District of Columbia Medical Power of Attorney has been generated as part of a long-term plan or made as a result of an unexpected emergency, notarization and/or witnesses can help to protect your agent if their privileges are questioned.
At times, when discussing the subjects of estate planning and elder care with legal or medical professionals, you or a loved one may hear the terms "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" being used together or interchangeably. In short, they're one and the same. That being said, you should keep in mind that it's certainly possible to have power of attorney over affairs that are not related to health care. In that case, "proxy" is not commonly used.
District of Columbia Medical PoA forms are normally straightforward, but you or your agent might still have questions. Finding a legal professional to comment on your District of Columbia Medical Power of Attorney might be expensive. A more cost-effective way to double-check your document would be to go through attorney services at Rocket Lawyer. When you sign up for a Premium membership, you can get your documents reviewed or ask specific questions. As always, Rocket Lawyer is here for you.
The fees associated with finding and working with your average attorney to produce a medical Power of Attorney could add up to anywhere from $200 to $500, depending on your location. When using Rocket Lawyer, you are not just filling out a Power of Attorney template. In case you ever need support from a lawyer, your Premium membership offers up to a 40% discount when you hire an Rocket Lawyer network attorney.
After making this document using Rocket Lawyer, you'll have the ability to get to it anytime, anywhere. With a Rocket Lawyer membership, you can make edits, print it out, and/or sign it. Alongside your Power of Attorney, you will discover a checklist of suggested actions to take after your document is finished. Your agent(s) and care providers should get a copy of the final document.
The guidelines will vary in each state; however, in the District of Columbia, your document will need the signatures of two witnesses. Your witnesses should not be anyone who is financially responsible for your health care, nor should they be anyone who is an employee of your attending physician or healthcare facility. Heirs, beneficiaries, and family members (including adopted children or your spouse) are also prohibited. Finally, as a general principle, witnesses will need to be over 18 years old, and no witness should also be acting as your Power of Attorney agent.
See District of Columbia Medical/Healthcare Power of Attorney law: § 21–2205
