Delaware Durable Medical Power of Attorney Form

The Delaware Power Of Attorney For Health Care form is a document which legally allows a Principal to appoint an `Agent` who can act as the power of attorney with regards to the patient`s health care in case they become so ill that they are unable to make vital decisions themselves. The document requires two witnesses, one witness then they may not be a relative or health care provider of the principal. The document is in accordance with the US statutes § 2501 – 2518.

How to Write

1) The principal must enter their Personal Information in the blank fields.

  • Full name..
  • State.
  • Date form was written.
  • Date of birth.

 

Part 1. Health Care Agent

The Agents Personal Information must be entered in the blank fields.

  • Full name
  • Address
  • ZIP code
  • Daytime telephone number
  • Other telephone number

 

Part 2. Choosing A Back Up Agent (Optional)

The Back Up Agents Personal Information (In case the first choice agents are unavailable) must be entered in the blank fields.

  • Full name
  • Address
  • ZIP code
  • Daytime telephone number
  • Other telephone number

 

Part 3. The Agents Powers

The principal must carefully read the list of agents requirements, especially the first power, initialing in the space provided.

  • Initial

 

Part 4. Special Instructions Or Limitations Of Agents Power

  • Enter in the blank space any other special requirements or limitations.

 

Part 7. Sign

The principal must enter their personal details.

  • Signature
  • Print full name
  • Date

 

Statement By The Witnesses

The witnesses must enter their personal details.

  • Print full name
  • Signature
  • Date
  • Address
  • ZIP code

Residents of Missouri, North Carolina, South Carolina or West Virginia,  must have this form notarized.

The details of the notary must be entered.

  • State
  • County
  • Date
  • Name of Principal
  • Names of witnesses
  • Signature of notary
  • Date commission expires