Health Care Power of Attorney Form - North Carolina

HEALTH CARE POWER OF ATTORNEY
NOTE: YOU SHOULD USE THIS DOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE
AGENT IF YOU ARE COMFORTABLE GIVING THAT PERSON BROAD AND SWEEPING POWERS
TO MAKE HEALTH CARE DECISIONS FOR YOU. THERE IS NO LEGAL REQUIREMENT THAT
ANYONE EXECUTE A HEALTH CARE POWER OF ATTORNEY.
EXPLANATION: You have the right to name someone to make health care decisions for you when you
cannot make or communicate those decisions. This form may be used to create a health care power of
attorney, and meets the requirements of North Carolina law. However, you are not required to use this
form, and North Carolina law allows the use of other forms that meet certain requirements. If you prepare
your own health care power of attorney, you should be very careful to make sure it is consistent with
North Carolina law.
This document gives the person you designate as your health care agent broad powers to make health
care decisions for you when you cannot make the decision yourself or cannot communicate your decision
to other people. You should discuss your wishes concerning life-prolonging measures, mental health
treatment, and other health care decisions with your health care agent. Except to the extent that you
express specific limitations or restrictions in this form, your health care agent may make any health care
decision you could make yourself.
This form does not impose a duty on your health care agent to exercise granted powers, but when a
power is exercised, your health care agent will be obligated to use due care to act in your best interests
and in accordance with this document.
This Health Care Power of Attorney form is intended to be valid in any jurisdiction in which it is presented,
but places outside North Carolina may impose requirements that this form does not meet.
If you want to use this form, you must complete it, sign it, and have your signature witnessed by two
qualified witnesses and proved by a notary public. Follow the instructions about which choices you can
initial very carefully. Do not sign this form until two witnesses and a notary public are present to watch
you sign it. You then should give a copy to your health care agent and to any alternates you name. You
should consider filing it with the Advance Health Care Directive Registry maintained by the North Carolina
Secretary of State: http://www.nclifelinks.org/ahcdr/
1. Designation of Health Care Agent.
I, _____________________, being of sound mind, hereby appoint the following person(s) to serve as my
health care agent(s) to act for me and in my name (in any way I could act in person) to make health care
decisions for me as authorized in this document. My designated health care agent(s) shall serve alone,
in the order named.
A. Name:
Home Telephone:
Home Address:
Work Telephone:
Cellular Telephone:
B. Name:
Home Telephone:
Home Address:
Work Telephone:
Cellular Telephone:
C. Name:
Home Telephone:
Home Address:
Work Telephone:
Cellular Telephone:
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Health Care Power of Attorney Form - North Carolina PDF

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