North Dakota Medical Power of Attorney
This Medical Power of Attorney is governed by the laws of the State of North Dakota. It is a legal document that allows you, the Principal, to designate an individual, known as an Agent, to make health care decisions on your behalf should you become unable to do so. This document is essential for ensuring your health care preferences are honored.
Principal Information
Full Name: ____________________________________________
Date of Birth: _________________________________________
Address: ______________________________________________
_______________________________________________________
Phone Number: __________________________________________
Agent Information
Full Name: ____________________________________________
Relationship to Principal: _______________________________
Address: ______________________________________________
_______________________________________________________
Primary Phone Number: ___________________________________
Alternative Phone Number: _______________________________
Alternate Agent Information (Optional)
Full Name: ____________________________________________
Relationship to Principal: _______________________________
Address: ______________________________________________
_______________________________________________________
Primary Phone Number: ___________________________________
Alternative Phone Number: _______________________________
In the event that my primary Agent is unable, unwilling, or unavailable to serve, I designate the above-named Alternate Agent to step in and make health care decisions on my behalf.
General Powers of the Agent
Under the laws of North Dakota, I grant my Agent the following powers:
- To make any and all health care decisions on my behalf when I am incapable of making them myself.
- To provide, refuse, or withdraw consent on my behalf for any and all types of health care, including but not limited to, medical and surgical treatments.
- To access my medical records and disclose them to others as necessary for my health care.
- To decide on my admission to or discharge from medical facilities such as hospitals and nursing homes.
- To request, refuse, or withdraw any and all types of health care, including life-prolonging interventions.
This durable power of attorney for health care becomes effective immediately upon the signing of this document and remains in effect indefinitely unless I state otherwise.
Special Instructions (Optional)
Use the space below to add any specific instructions or limitations you wish to place on your Agent’s powers, such as preferences regarding end-of-life care, religious considerations in treatment, or any other wishes:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signatures
By signing below, I acknowledge that I understand the nature and purpose of this document and I am of sound mind to make this designation.
_________________________________ _________
Principal's Signature Date
State of North Dakota
County of _______________________
Subscribed and sworn to (or affirmed) before me on this ___ day of __________, 20__, by ________________________ (name of Principal).
_________________________________
Notary Public
My Commission Expires: __________
_________________________________ _________
Agent's Signature Date
This document does not authorize the Agent to make financial decisions on behalf of the Principal.
It is recommended to review this Medical Power of Attorney periodically and update it if your preferences or your designated Agent’s situation changes.
