Hawaii Medical Power of Attorney
This document allows you to designate a person to make medical decisions on your behalf, according to Hawaii state laws.
Principal Information:
- Name: ____________________________________
- Address: __________________________________
- City, State, Zip Code: ____________________
- Date of Birth: ____________________________
Agent Information:
- Name: ____________________________________
- Address: __________________________________
- City, State, Zip Code: ____________________
- Phone Number: ____________________________
Alternate Agent (Optional):
- Name: ____________________________________
- Address: __________________________________
- City, State, Zip Code: ____________________
Grant of Authority:
I, the undersigned Principal, hereby appoint the above-named Agent as my Medical Power of Attorney. This authority includes the ability to:
- Make decisions regarding my medical care.
- Access my medical records.
- Consent to or refuse treatment on my behalf.
Effective Date:
This Medical Power of Attorney becomes effective when I am unable to make my own medical decisions.
Signature:
Principal Signature: ____________________________
Date: _________________________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to me or my Agent. The witnesses should sign below:
- Witness Name: _______________________________ Signature: ________________________
- Witness Name: _______________________________ Signature: ________________________
Notarization (Optional but recommended):
State of Hawaii, County of ____________
On this ____ day of __________, 20__, before me appeared ____________________, known to me to be the person described herein, and acknowledged that they executed the same.
Notary Public Signature: _______________________ My Commission Expires: _____________