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WARNING TO PERSON EXECUTING THIS DOCUMENT
This is an important legal document that is authorized by the general laws of this state. Before executing this document, you should know these important facts:
You must be at least eighteen years of age for this document to be legally valid and binding.
This document gives the person you designate as your Agent (the Attorney-in-Fact) the power to make health care decisions for you. Your Agent must act consistently with your desires as stated in this document or otherwise made known.
Except as you otherwise specify in this document, this document gives your Agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.
Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision.
This document gives your Agent authority to request, consent to, refuse to consent to, or to withdraw consent for any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition if you are unable to do so yourself. This power is subject to any statement of your desires and any limitation that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your Agent to make health care decisions for you if your Agent authorizes anything that is illegal; acts contrary to your known desires; or where your desires are not known, does anything that is clearly contrary to your best interest.
Unless you specify a specific period, this power will exist until you revoke it. Your Agent's power and authority ceases upon your death.
You have the right to revoke the authority of your Agent by notifying your Agent or your treating doctor, hospital, or other health care provider orally or in writing of the revocation.
Your Agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document.
This document revokes any prior Durable Power of Attorney for Health Care.
You should carefully read and follow the witnessing procedure described at the end of this form. This document will not be valid unless you comply with the witnessing procedure.
If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.
Your Agent may need this document immediately in case of an emergency that requires a decision concerning your health care. Either keep this document where it is immediately available to your Agent and Alternate Agents, if any, or give each of them an executed copy of this document. You should give your doctor an executed copy of this document.
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
. DESIGNATION OF HEALTH CARE AGENT. I, , of , , do hereby designate and appoint:
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
as my Attorney-in-Fact (Agent) to make health care decisions for me as authorized in this document.
For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical condition.
I UNDERSTAND THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS FOR ME IF I AM UNABLE TO MAKE AND COMMUNICATE HEALTH CARE DECISIONS FOR MYSELF (I know I can change my agent or alternate agent at any time and I know I do not have to appoint an agent or an alternate agent)
(None of the following may be designated as your Agent: (1) your treating health care provider, (2) a nonrelative employee of your treating health care provider, (3) an operator of a community care facility, or (4) a nonrelative employee of an operator of a community care facility.)
. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney for Health Care.
. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document. My health care agent is automatically given the powers listed below in (A) through (D). My health care agent must follow my health care instructions in this document or any other instructions I have given to my agent. If I have not given health care instructions, then my agent must act in my best interest.
Whenever I am unable to make and communicate health care decisions for myself, my health care agent has the power to:
(A) Make any health care decision for me. This includes the power to give, refuse, or withdraw consent to any care, treatment, service, or procedures. This includes deciding whether to stop or not start health care that is keeping me or might keep me alive and deciding about mental health treatment.
(B) Choose my health care providers.
(C) Choose where I live and receive care and support when those choices relate to my health care needs.
(D) Review my medical records and have the same rights that I would have to give my medical records to other people.
(If you want to limit the authority of your Agent to make health care decisions for you, you can state the limitations below.)
. BURIAL.
. DURATION.
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. SEVERABILITY. If any provision in 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.
(YOU MUST DATE AND SIGN THIS DOCUMENT)
I sign my name to this on the _____ day of ____________________, _____, at , North Dakota.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
(THIS HEALTH CARE DIRECTIVE WILL NOT BE VALID UNLESS IT IS NOTARIZED OR SIGNED BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS HEALTH CARE DIRECTIVE.)
NOTARY PUBLIC OR STATEMENT OF WITNESSES
This document must be (1) notarized or (2) witnessed by two qualified adult witnesses. The person notarizing this document may be an employee of a health care or long-term care provider providing your care. At least one witness to the execution of the document must not be a health care or long-term care provider providing you with direct care or an employee of the health care or long-term care provider providing you with direct care. None of the following may be used as a notary or witness:
1. A person you designate as your agent or alternate agent;
2. Your spouse;
3. A person related to you by blood, marriage, or adoption;
4. A person entitled to inherit any part of your estate upon your death; or
5. A person who has, at the time of executing this document, any claim against your estate.
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
ACCEPTANCE OF APPOINTMENT OF POWER OF ATTORNEY
(To be effective, the Agent must accept the appointment in writing.)
I accept this appointment and agree to serve as Agent for health care decisions. I understand I have a duty to act consistently with the desires of , the Principal, as expressed in this appointment. I understand that this document gives me authority over health care decisions for only if becomes incapable. I understand that I must act in good faith in exercising my authority under this power of attorney. I understand that may revoke this power of attorney at any time in any manner.
If I choose to withdraw during the time is competent I must notify of my decision. If I choose to withdraw when is incapable of making 's health care decision, I must notify 's physician.
__________________
Date
________________________________________
PRINCIPAL'S STATEMENT
I have read a written explanation of the nature and effect of an appointment of a health care agent that is attached to my health care directive.
_________________
Date
_____________________________________
| (Signature of Principal) |
SPECIAL STATEMENT
1. This Durable Power of Attorney for Health Care is NOT effective if at the time of execution is a resident of a long-term care facility unless a recognized member of the clergy, an attorney licensed to practice in North Dakota, or a person designated by the Department of Human Services or the district court for the County in which the facility is located signs a statement affirming that the person has explained the nature and effect of the Durable Power of Attorney for Health Care to or unless acknowledges in writing that he or she has read the warning prefacing this form which explains the nature and effect of a Durable Power of Attorney for Health Care.
2. A Durable Power of Attorney for Health Care is NOT effective if at the time of execution is being admitted to or is a patient in a hospital unless a person designated by the hospital or an attorney licensed to practice in this state signs a statement that the person has explained the nature and effect of the Durable Power of Attorney for Health Care to or unless acknowledges in writing that he or she has read the warning prefacing this form which explains the nature and effect of a Durable Power of Attorney for Health Care.
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It's fast and simple to assign or receive the support you may need using a free North Dakota Medical Power of Attorney template from Rocket Lawyer:
This method, in most cases, would end up being much more affordable than finding and hiring your average attorney. If needed, you may prepare a Medical PoA on behalf of your spouse, an elderly parent, or another family member, and then help that person sign when ready. Please remember that for this document to be valid, the principal must be an adult who is mentally competent when they sign. In the event that the principal has already been declared incompetent, a court-appointed conservatorship generally will be required. When managing this scenario, it's best to talk to a lawyer .
Every adult should have a Medical Power of Attorney. Even though it's difficult to acknowledge, a day might come when you can no longer make your own healthcare decisions. Here are some typical situations where PoA forms might be helpful:
Regardless of whether this North Dakota Medical Power of Attorney is being made as a result of an emergency or as part of a long-term plan, witnesses and notarization will often help to protect your agent if someone questions their power and authority.
Sometimes, in the process of researching the subjects of estate planning and/or elder care, you or a loved one might see "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" used together. In actuality, they're the same. That being said, you should keep in mind that it's absolutely possible to have agency over matters that aren't health-related. In that case, "proxy" typically is not the preferred term.
North Dakota Medical PoA forms are generally simple, but you or your agent(s) could still have legal questions. It will vary depending on whom you contact, but quite often some lawyers will not even accept requests to review your document if they were not the author. A more favorable approach to consider is to go through Rocket Lawyer attorney services. If you sign up for a Premium membership, you will be able to ask for feedback from an Rocket Lawyer network attorney with relevant experience or ask additional legal questions related to your Medical Power of Attorney. As always, we're here to support you.
The cost of meeting and hiring a traditional attorney to generate a Medical Power of Attorney could be anywhere between $200 and $500. Unlike the other sites that you might stumble upon, Rocket Lawyer offers much more than a Power of Attorney template. If you ever require assistance from a lawyer, your Rocket Lawyer membership offers up to 40% in savings when you hire an attorney from our network.
Once you have completed your Healthcare PoA document on Rocket Lawyer, you'll be able to retrieve it anytime and anywhere. You are encouraged to try any of these actions with your PoA: editing it, downloading it as a Word document or PDF file, printing it out, and signing it. Attached alongside each Power of Attorney form, there is a series of tips to follow while finalizing the document. Your agent(s), care providers, and other impacted parties should get copies of your final document.
The requirements and restrictions governing PoA forms are different by state; however, in North Dakota, your document must be acknowledged by a notary public or signed by two witnesses. At least one witness to your PoA form must not be anyone providing you with direct health care or long-term care, or any employee of such a provider. Family members (including your spouse or adoptees), heirs, and beneficiaries also cannot be witnesses. As a basic rule, witnesses will need to be over 18 years old, and none of them should simultaneously be named as your Power of Attorney agent.
See North Dakota Medical/Healthcare Power of Attorney law: § 23-06.5
