Living Will Forms > Free Ohio Living Will Forms | Advance Health Care Directive > Ohio Durable Medical Power of Attorney Form

Ohio Durable Medical Power of Attorney Form

The Ohio medical power of attorney for health care legally binds the principal and another person appointed by the principal, called the `Agent`, to allow the power over their health care treatment to be passed on to the agent under certain circumstances. This will happen should the principal become no longer able to make these decisions themselves. The time when this power is valid depends on the principal`s personal preference The document applies to US statutes § 1337.11 to .17 and requires the signatures of either a notary or two witnesses. If the patient is pregnant  the power of attorney is no longer acceptable.

How to Write

Health Care Power Of Attorney

The principal must enter their personal details.

  • Name.
  • Date of birth.

 

Agents

The agent`s and alternative agent`s details must be entered.

  • Agent`s name.
  • Agent`s address.
  • Agent`s telephone number.
  • Alternatives names.
  • Alternatives addresses.
  • Alternatives telephone numbers.

 

Special Instructions

The principal must initial part 3 if they wish to give their agent the authority to life sustaining treatment including artificial hydration and nutrition.

 

Additional Instructions And Limitations

The principal must enter the details of any other specific wishes or restrictions regarding their medical health care.

 

Living Will

The principal must initial to show they have completed a living will form.

  • Initial `Yes`.
  • Initial `No`.

Anatomical Gift

The principal must initial to show their wishes regarding an anatomical donation.

  • Initial `Yes`.
  • Initial `No`.

Donor Registry Enrollment Form

The principal must initial to show they have completed a donor registry enrollment form.

  • Initial `Yes`.
  • Initial `No`.

 

Signature

The principal must enter their details.

  • Date.
  • Principal`s signature.

 

Witnesses And Notary

The witnesses and notary`s details must be entered.

  • Witnesses signature.
  • Witnesses name.
  • Witnesses address.
  • Date.
  • County.
  • Date.
  • Name of principal.
  • Name of notary.
  • Date of expiration of commission.