MEDICAL POWER OF ATTORNEY & HEALTHCARE PROXY
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Effective Date: ________________________________________________________
Place: _________________________________________________________________

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1. Parties
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This document is made on ____________________ (____________________) by:

Principal
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

In favor of:

Healthcare Agent
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

2. SUBJECT-MATTER SCHEDULE & SPECIFICATIONS
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Decisions the Agent May Make: __________________________________________
Limitations: ___________________________________________________________
Alternate Agent: _______________________________________________________
When the Authority Begins: _____________________________________________

3. EXECUTION & SIGNATURES
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Principal

Signature: _____________________________________________________________

Full Legal Name: _______________________________________________________
Date: __________________________________________________________________