Page 1 of 4
Health Care Power of Attorney
For North Carolina
A Practical Form for All Adults
This form allows you to express your wishes for future health care and to guide decisions about that
care. It does not address financial decisions. Although there is no legal requirement for you to have a
health care power of attorney, completing this form may help you to receive the health care you
If you are 18 years old or older and are able to make and communicate health care decisions, you may
use this form.
This form complies with North Carolina law (in NCGS § 32A-15 through 32A-27).
1. What is a health care power of attorney? A health care power of attorney is a legal document in
which you name another person, called a “health care agent,” to make health care decisions for
you when you are not able to make those decisions for yourself.
2. Who can be a health care agent? Any competent person who is at least 18 years old and who is
not your paid health care provider may be your health care agent.
3. How should you choose your health care agent? You should choose your health care agent very
carefully, because that person will have broad authority to make decisions about your health care.
A good health care agent is someone who knows you well, is available to represent you when
needed, and is willing to honor your wishes. It is very important to talk with your health care agent
about your goals and wishes for your future health care, so that he or she will know what care you
4. What decisions can your health care agent make? Unless you limit the power of your health care
agent in Section 2 of this form, your health care agent can make all health care decisions for you,
▪ starting or stopping life-prolonging measures
▪ decisions about mental health treatment
▪ choosing your doctors and facilities
▪ reviewing and sharing your medical information
▪ autopsies and disposition of your body after death
5. Can your health care agent donate your organs and tissues after your death? Yes, if you choose
to give your health care agent this power on the form. To do this, you must initial the statement in
6. When will this health care power of attorney be effective? This document will become effective if
your doctor determines that you have lost the ability to make your own health care decisions.
901109 R 08/21/2013 AD0088 *AD0088*