Minnesota Medical Power of Attorney
This Medical Power of Attorney is a legal document that grants an agent the authority to make healthcare decisions on behalf of the principal, in accordance with the Minnesota Health Care Directive Act, if the principal is unable to make decisions for themselves. This document ensures that the principal's health care preferences are honored and respected.
Principal Information:
Name: _________________________________________________
Address: ______________________________________________
City: ______________________ State: MN Zip: ____________
Phone Number: _________________________________________
Agent Information:
Name: _________________________________________________
Address: ______________________________________________
City: ______________________ State: MN Zip: ____________
Phone Number: _________________________________________
Relationship to Principal: _____________________________
Alternate Agent Information: (Optional)
Name: _________________________________________________
Address: ______________________________________________
City: ______________________ State: MN Zip: ____________
Phone Number: _________________________________________
Relationship to Principal: _____________________________
By signing this document, the Principal grants the Agent the power to make health care decisions including, but not limited to, the consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. This power is subject to any statements or limitations set forth below:
_________________________________________________________
_________________________________________________________
Signatures:
This document will not be effective unless it is signed by the principal or by another individual in the principal's presence and at the principal's express direction. It must be acknowledged before a notary public or other individual authorized by law to take acknowledgments.
Principal's Signature: _____________________ Date: _________
Agent's Signature: ________________________ Date: _________
State of Minnesota
County of ___________________
This document was acknowledged before me on (date) __________ by (name of principal) _______________________________.
______________________________________
Signature of Notary Public or Other Authorized Individual
My commission expires: __________________
Instructions to the Agent: As the agent granted the authority to make health care decisions on behalf of the principal, you are expected to act in the principal's best interest, according to the wishes of the principal as expressed in this document or as otherwise communicated to you. If the principal's wishes are not specifically expressed or known, you are expected to act in what you believe to be the principal's best interest.
Revocation: The principal retains the right to revoke this Medical Power of Attorney at any time, as long as they are competent. This revocation must be made in writing and communicated to the healthcare provider and the agent.