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DURABLE POWER OF ATTORNEY FOR HEALTH CARE
. 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: The following individuals may not act as your health care Agent:
(1) Any of your physicians;
(2) An employee of any of your physicians;
(3) Owners, administrators, or employees of the health care facility where you reside or receive care.
Unless the above person is your spouse, adult child, brother, or sister.
. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney for Health Care. 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, In making any decision, my Agent shall attempt to discuss the proposed decision with me to determine my desires if I am able to communicate in any way. In addition, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent.
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate my Agent (or Alternate Agent) to serve as my Guardian.
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate
| Name: |
| Address: |
| , |
to serve as my Guardian.
. 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 CAREFULLY AND FOLLOW THE WITNESSING PROCEDURE.
IT REQUIRES TWO WITNESSES AND A NOTARY
TO FORMALIZE THIS DOCUMENT.
STATEMENT OF WITNESSES
I declare that who signed or acknowledged this document (the "Principal") has identified himself or herself to me, that 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 WASHINGTON
COUNTY OF _________________________
On this day personally appeared before me , to me known to be the individual described in and who executed the within and foregoing instrument, and acknowledged that he/she signed the same as his/her free and voluntary act and deed for the uses and purposes therein mentioned.
Given under my hand and official seal this ______ day of ____________________, _____.
My commission expires: _________________________
________________________________________
NOTARY PUBLIC in and for the State of Washington;
residing at
________________________________________
________________________________________
________________________________________
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It is simple and easy to assign or receive the support you may need with a free Washington Medical Power of Attorney template from Rocket Lawyer:
This method, in many cases, would be notably less expensive than finding and hiring a conventional provider. If necessary, you can prepare this Medical PoA on behalf of a family member, and then have that person sign after you've drafted it. Please keep in mind that for a Power of Attorney to be considered valid, the principal must be mentally competent when they sign. If the principal is already incapacitated and unable to make their own decisions, a court-appointed conservatorship may be necessary. When dealing with such a scenario, it would be important to speak with an attorney .
Every adult should have a Medical Power of Attorney. Even though it is challenging to acknowledge, there might come a time when you are not able to make your own medical decisions. Common circumstances where PoA forms would be helpful include:
Regardless of whether this Washington Medical Power of Attorney is being produced in response to an unexpected emergency or as part of a forward-looking plan, witnesses and/or notarization can often help to protect your agent if their privileges and authority are challenged.
In the process of researching the topics of estate planning and/or elder care, you might hear "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" being used together. In reality, they're the same. That being said, you should keep in mind that it's absolutely possible to have power of attorney over affairs that aren't health-related. In that case, "proxy" typically is not the term of choice.
Washington Medical PoA forms are typically straightforward, but you might need legal advice. Getting a legal professional to review your Washington Medical Power of Attorney could be fairly time-intensive. A more cost-effective route would be via the Rocket Lawyer attorney network. By becoming a Premium member, you can have your document reviewed by an experienced attorney. As always, Rocket Lawyer will be here to support you.
The cost of finding and hiring a legal provider to make a Medical Power of Attorney might add up to between two hundred and five hundred dollars, based on your location. Rocket Lawyer can offer much more protection than most other Power of Attorney template websites that you may encounter. As a Rocket Lawyer Premium member, you can get up to 40% in savings when hiring an attorney from our Rocket Lawyer attorney network.
Each Power of Attorney has its own checklist of next steps to take to finalize your document. Feel free to take any or all of the following actions related to your PoA: editing it, saving it as a Word or PDF file, printing it, or signing it. Finally, your agent(s), care providers, and other impacted parties should get a copy of the final document.
The specifications and restrictions governing PoA forms will vary in each state; however, in Washington, your Power of Attorney will require the signatures of two witnesses or a notary public. The witnesses to your form shouldn't include any care providers, whether at your home, at an adult family home, or at a long-term care facility, if you live there. Your spouse and any other family members are also restricted from being witnesses. Finally, as a general rule, your witness(es) will need to not be under the age of 18, and none of them should also be designated as your Power of Attorney agent.
See Washington Medical/Healthcare Power of Attorney law: RCW 11.125.90
