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HEALTH CARE POWER OF ATTORNEY
. DESIGNATION OF HEALTH CARE AGENT. I, , of , , appoint:
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
as my Agent to make health care and personal decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.
NOTICE: Generally you should not appoint any of the following persons as your Agent:
(1) your treating physician or health care provider;
(2) an employee of your physician or health care provider unless the person is your relative;
(3) your residential care provider; or
(4) an employee of your residential care provider unless the person is your relative.
. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Health Care Power of Attorney. This power of attorney shall take effect upon my disability, incapacity, or incompetency, and shall continue during such disability, incapacity, or incompetency.
. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I grant to my Agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, My Agent shall not make a health care decision for me if my attending physician has determined in good faith that I have decisional capacity.
Whenever making any health care decision, my Agent shall consult the recommendation of my attending physician, consider the decision I would have made if I had the decisional capability, if known, and the decision that my Agent believes to be in my best interests, and make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent. All such decisions shall be made in accordance with accepted medical practice.
SECOND ALTERNATE AGENT
| Agent Name: |
| 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.
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration.
Signed on _____ day of _______________, _____.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
READ AND CAREFULLY FOLLOW THE WITNESSING PROCEDURE. IT REQUIRES TWO WITNESSES AND A NOTARY TO FORMALIZE THIS DOCUMENT ALTHOUGH YOUR STATE HAS NOT ENACTED A HEALTH CARE POWER OF ATTORNEY STATUTE.
STATEMENT OF WITNESSES
I declare that the person who signed or acknowledged this document, (the "Principal") has identified himself or herself to me, that voluntarily signed or acknowledged this document in my presence, that appears to be of sound mind, and under no duress, fraud or undue influence. I am not the person appointed as Agent or Alternate Agent by this document, nor am I a provider of health or residential care, an employee of a provider of health or residential care, the operator of a community care facility, or an employee of an operator of a health care facility.
I further declare that I am not related to by blood, marriage, or adoption, and to the best of my knowledge, I am not a creditor of or entitled to any part of the estate of under a will now existing or by operation of law.
| Witness Signature: | ________________________________________ |
Date: ______________________________
| Witness Signature: | _________________________________________ |
Date: ______________________________
State of _________________________,
County of _________________________ ss:
On this ______ day of ____________________, _____, , known to me (or satisfactorily proven) to be the person named in the foregoing instrument, personally appeared before me, a Notary Public, within and for the said State and County, and acknowledged that he/she freely and voluntarily executed the same for the purposes stated in the document.
My commission expires: ____________________
________________________________________
Notary Public
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It's quick and easy to grant or receive the support you need with a free South Dakota Medical Power of Attorney template from Rocket Lawyer:
This solution will often end up being notably less expensive than meeting and hiring the average provider. If necessary, you can start a Medical PoA on behalf of a family member, and then have them sign when ready. Please note that for a Power of Attorney to be considered valid, the principal must be an adult who is mentally competent when they sign. If the principal has already been declared incompetent, a conservatorship could be required. When managing such a scenario, it's best to speak with a lawyer .
Everyone over 18 years old should have a Medical Power of Attorney. Although it can be challenging to think about, there might come a time when you cannot make healthcare decisions on your own. Common occasions in which you may find PoA forms to be helpful include:
Regardless of whether your South Dakota Medical Power of Attorney is being made as a result of an urgent issue or as part of a forward-looking plan, witnesses and/or notarization are strongly recommended as a best practice for protecting your agent if their power and authority are doubted.
At times, in discussing the subjects of elder care and/or estate planning with healthcare or legal professionals, you or a loved one may hear "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" being used together or interchangeably. In reality, they are the same. That said, you should keep in mind that it is certainly possible to establish power of attorney over affairs that aren't health-related, in which case, "proxy" is not normally used.
South Dakota Medical PoA forms are typically straightforward, but you may still have questions. Getting a second opinion on the document may take a long time if you attempt to do it by yourself. An alternate approach worth consideration is to request help from Rocket Lawyer attorney services. Rocket Lawyer Premium members can ask for a document review from an Rocket Lawyer network attorney with relevant experience or pose additional legal questions. As always, you can Live Confidently® with Rocket Lawyer by your side.
The fees associated with meeting and hiring your average legal provider to draft a Medical Power of Attorney could be anywhere between two hundred and five hundred dollars, depending on your location. Rocket Lawyer isn't your average Power of Attorney template provider. With us, anyone under a Premium membership can take advantage of up to a 40% discount when hiring an attorney from our Rocket Lawyer attorney network.
Attached to your Power of Attorney, you'll discover a list of recommended steps you should take once the document is completed. You are encouraged to take any of these actions with your PoA: making edits, saving it as a Word document or PDF file, printing it out, and/or signing it. Finally, your agent(s) and care providers should receive copies of the fully executed document.
The specific requirements and restrictions for PoA forms are different in each state; however, in South Dakota, your Power of Attorney will need notarization or the signatures of two witnesses. Finally, as a general rule, witnesses should not be under 18 years old, and none should also be your Power of Attorney agent.
See South Dakota Medical/Healthcare Power of Attorney law: Chapter 34-12C
