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HEALTHCARE POWER OF ATTORNEY
Declaration made this _____ day of _______________, _____. I, , willingly and voluntarily make known my wishes in the event that I am incapable of making an informed decision, as follows:
To consent to or refuse or withdraw consent to any type of medical care, treatment, surgical procedure, diagnostic procedure, medication and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, artificially administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the power to consent to the administration of dosages of pain relieving medication in excess of standard dosages in an amount sufficient to relieve pain, even if such medication carries the risk of addiction or inadvertently hastens my death.
To request, receive, and review any information, verbal or written, regarding my physical or mental health, including but not limited to, medical and hospital records, and to consent to the disclosure of this information.
To employ and discharge my health care providers.
To authorize my admission to or discharge (including transfer to another facility) from any hospital, hospice, nursing home, adult home or other medical care facility. If I have authorized admission to a health care facility for treatment of mental illness, that authority is stated elsewhere in this power of attorney for health care.
To authorize my admission to a health care facility for the treatment of mental illness for no more than 10 calendar days provided I do not protest the admission and a physician on the staff of or designated by the proposed admitting facility examines me and states in writing that I have a mental illness and I am incapable of making an informed decision about my admission, and that I need treatment in the facility; and to authorize my discharge (including transfer to another facility) from the facility;
To authorize my admission to a health care facility for the treatment of mental illness for no more than 10 calendar days, even over my protest, if a physician on the staff of or designated by the proposed admitting facility examines me and states in writing that I have a mental illness and I am incapable of making an informed decision about my admission, and that I need treatment in the facility; and to authorize my discharge (including transfer to another facility) from the facility. [My physician or licensed clinical psychologist hereby attests that I am capable of making an informed decision and that I understand the consequences of this provision of my power of attorney for health care: ______________(INITIAL)];
To continue to serve as my agent even in the event that I protest the agent's authority after I have been determined to be incapable of making an informed decision.
To authorize my participation in any health care study approved by an institutional review board or research review committee according to applicable federal or state law that offers the prospect of direct therapeutic benefit to me.
To authorize my participation in any health care study approved by an institutional review board or research review committee pursuant to applicable federal or state law that aims to increase scientific understanding of any condition that I may have or otherwise to promote human well-being, even though it offers no prospect of direct benefit to me.
To make decisions regarding visitation during any time that I am admitted to any health care facility, consistent with the following directions:
To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers.
________________________________________.
This power of attorney for health care shall not terminate in the event of my disability.
By signing below, I indicate that I am emotionally and mentally competent to make this power of attorney for health care and that I understand the purpose and effect of this document. I understand I may revoke all or any part of this document at any time (i) with a signed, dated writing; (ii) by physical cancellation or destruction of this power of attorney for health care by myself or by directing someone else to destroy it in my presence; or (iii) by my oral expression of intent to revoke.
Date Signed: _______________ _____, _____.
| Declarant Signature: | ______________________________________ |
| Name: |
| Address: |
The Declarant signed the foregoing power of attorney for health care in my presence. I am not the spouse or blood relative of the Declarant.
| Witness Signature: | ________________________________________ |
| Witness Signature: | ________________________________________ |
| _____ | (your Agent) |
| * | You should discuss the document and your wishes with any person you want to designate as an Agent before doing so to assure they agree to act on your behalf. |
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It is fast and easy to give or receive the authority you may need with a free Virginia Medical Power of Attorney template from Rocket Lawyer:
This solution will often be notably less time-consuming than hiring and working with a conventional attorney. If needed, you may prepare this Medical PoA on behalf of an elderly parent, a spouse, or another family member, and then have them sign once you've drafted it. Please note that for this document to be accepted as legally valid, the principal must be a mentally competent adult when they sign. If the principal is already unable to make their own decisions, a court-appointed conservatorship may be required. When managing this scenario, it is a good idea for you to speak to an attorney .
Anyone who is over 18 ought to have a Medical Power of Attorney. While it can be tough to think about, a time may come when you cannot make healthcare decisions on your own. Typical occasions where you might find PoA forms to be useful include:
Whether your Virginia Medical Power of Attorney is being drafted as part of a forward-looking plan or produced in response to an emergency, witnesses and notarization are highly encouraged for protecting your document if a third party challenges its validity.
When discussing the subjects of estate planning and elder care with medical or legal professionals, you or a loved one might hear "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" used together or interchangeably. In short, they are one and the same. That being said, you should keep in mind that it is possible to give power of attorney over matters that aren't related to health care. In that case, "proxy" generally is not the term of choice.
Virginia Medical PoA forms are generally straightforward; however, you or your agent(s) could still need advice. Locating an attorney to review your Virginia Medical Power of Attorney could be time-consuming and relatively expensive. A more cost-effective route is to request help from the Rocket Lawyer attorney network. As a Premium member, you can get your document examined by an attorney with relevant experience. As always, you can rest assured that Rocket Lawyer will be here for you.
The fees associated with meeting and hiring the average attorney to make a Medical Power of Attorney might total anywhere between two hundred and five hundred dollars, based on your location. Rocket Lawyer offers much more than most other Power of Attorney template websites that you might find. As a Rocket Lawyer member, you can get up to 40% in savings when hiring an attorney.
Once you've made a Healthcare PoA with the help of Rocket Lawyer, you'll be able to review it wherever and whenever you choose. With a membership, you may edit it, download it in PDF format or as a Word document, print it, or sign it. Attached to each Power of Attorney form, there will be a list of tips to follow while finalizing the document. Be sure that your agent(s) and care providers get a copy of the fully executed document.
The specific requirements vary in each state; however, in Virginia, your document will typically need to be signed by two witnesses. The document must be signed before a notary if you intend to grant an agent authority over your burial or cremation. As a basic standard, your witness(es) must be over 18 years old, and none of them should simultaneously be your agent.
See Virginia Medical/Healthcare Power of Attorney law: Title 54.1, Chapter 29, Article 8
