Michigan Medical Power of Attorney Template
This document serves as a Medical Power of Attorney in accordance with Michigan law. It allows you to appoint someone to make medical decisions on your behalf if you are unable to do so.
Principal Information:
- Name: ___________________________
- Date of Birth: ____________________
- Address: _________________________
- City: ____________________________
- State: Michigan
- Zip Code: ________________________
Agent Information:
- Name: ___________________________
- Address: _________________________
- City: ____________________________
- State: ___________________________
- Zip Code: ________________________
Durability of Power of Attorney:
This Medical Power of Attorney shall remain in effect until revoked by the Principal, unless otherwise specified.
Grant of Authority:
I hereby grant my Agent the authority to make decisions regarding my medical treatment, including but not limited to:
- Consent to or refuse medical treatment.
- Access my medical records and information.
- Make decisions regarding life-sustaining treatment.
Signatures:
By signing below, I affirm that I am of sound mind and that I understand the contents of this document.
Principal's Signature: ___________________________
Date: ___________________________
Witness Signature: ___________________________
Date: ___________________________
Notary Public:
State of Michigan
County of ___________________________
Subscribed and sworn before me on this ____ day of __________, 20__.
Notary Public Signature: ___________________________
My commission expires: ___________________________