North Carolina Medical Power of Attorney Form

The North Carolina Medical Power Of Attorney legally permits an appointed person, the agent, to make medical health care choices on behalf of the principal should they become unable to do so themselves through illnesses such as a coma or mental impairment. It requires two witnesses and a notary and is drawn up in accordance with the US Statutes § 32A- 15 to -27.The principal can choose the precise time this power of attorney is effective and they can also choose to invalidate it at any time.

How to Write

Health Care Power Of Attorney

Designation Of Health Care Agent

1) The principal must enter their details and the details of any agents.

  • Principal`s name.
  • Agents name.
  • Agent`s address.
  • Agent`s home/work/cellular telephone numbers.

 

Effectiveness Of Appointment

2) The principal must nominate two physicians.

 

Special Provisions And Limitations

5)  The principal must initial any relevant statements regarding the agent`s authority over limitations and special provisions to the principal`s health care.

A)

  •  Initial to not give the agent authority over artificial nutrition and enter any other special provisions.
  • Initial to not give the agent authority over artificial hydration and enter any other special provisions.

B)

  • Initial to give the agent authority over health care decisions and enter any other special provisions.

C)

  • Initial to give the agent authority over mental health care decisions and enter any other special provisions.

D)

  • Initial to give the agent authority over mental health care treatment and enter any other special provisions and details of any other advanced instruction for health care.

E)

  • Initial to give the agent authority over the autopsy and disposition of remains and enter any other special provisions.

 

Organ Donation

6) Details must be entered regarding the principal`s wishes as regards an anatomical donation.

  • Initial to donate any required anatomical parts.
  • Initial to only donate specific anatomical parts.
  • Initial to make an anatomical donation for study.
  • Initial and enter details of any specific requirements and limitations of the agent`s authority regarding an anatomical donation.

 

The principal witnesses and the notary must enter their details to acknowledge the document and it`s contents.

  • Date.
  • Principal`s signature.
  • Principal`s name.
  • Date.
  • Witnesses names.
  • County.
  • State.
  • Principal`s name.
  • Witnesses names.
  • Notary`s signature.
  • Name of notary.
  • Date of expiration of commission.