Ohio Medical Power of Attorney Template
This Ohio Medical Power of Attorney grants authority to an appointed person (hereinafter referred to as the "Agent") to make healthcare decisions on behalf of the person executing this document (hereinafter referred to as the "Principal") according to the Ohio Revised Code 1337.12 to 1337.17.
Date: ____________________
I, ____________________, residing at ____________________, being of sound mind, hereby appoint:
Name of Agent: ____________________
Address of Agent: ____________________
Phone Number of Agent: ____________________
as my Attorney-in-Fact ("Agent") to make health care decisions for me as authorized in this document. Should my primary Agent be unable or unwilling to serve, I designate the following as successor Agent:
Name of Successor Agent: ____________________
Address of Successor Agent: ____________________
Phone Number of Successor Agent: ____________________
The powers granted to my Agent include, but are not limited to, the following:
- Consenting to, refusing, or withdrawing any type of medical treatment, service, or procedure.
- Admitting or discharging me from any hospital, nursing home, or other medical care facility.
- Having access to my medical records and the authority to disclose them as necessary.
This Medical Power of Attorney becomes effective immediately upon signing and shall remain in effect until it is revoked.
I also understand that this document does not authorize my Agent to make decisions regarding the termination of life-sustaining treatment. For those decisions, a separate Living Will or Health Care Directive should be executed.
Signature of Principal: ____________________
Date: ____________________
Witness:
Name of Witness: ____________________
Address of Witness: ____________________
Signature of Witness: ____________________
Date: ____________________
This document was executed in accordance with Ohio law, confirming that the Principal is of sound mind and under no constraint or undue influence. The witnesses affirm that they are not the designated Agent, successor Agent, spouse, or relative of the Principal, nor are they directly involved in the healthcare of the Principal.