Alaska Medical Power of Attorney
This Medical Power of Attorney is created in accordance with the laws of the State of Alaska. This document allows you to appoint someone to make medical decisions on your behalf if you become unable to do so.
Principal Information:
Name: ___________________________
Address: _________________________
City, State, Zip: ________________
Date of Birth: ____________________
Agent Information:
Name: ___________________________
Address: _________________________
City, State, Zip: ________________
Phone Number: ____________________
Alternate Agent Information:
Name: ___________________________
Address: _________________________
City, State, Zip: ________________
Phone Number: ____________________
Effective Date:
This Medical Power of Attorney is effective upon the following condition:
- When I am unable to make my own medical decisions due to incapacity.
Agent's Authority:
The agent shall have the authority to make all healthcare decisions on my behalf, including but not limited to:
- Consent to or refuse medical treatment.
- Access my medical records.
- Make decisions about life-sustaining treatment.
Signature:
Principal's Signature: ___________________________
Date: ________________________________________
Witnesses:
This document must be witnessed by two individuals who are not related to the principal or the agent.
- Witness 1 Name: ___________________________
- Witness 1 Signature: ________________________
- Witness 2 Name: ___________________________
- Witness 2 Signature: ________________________
Notary Public:
State of Alaska
County of ___________________________
Subscribed and sworn to before me this _____ day of __________, 20__.
Notary Public Signature: _______________________
My Commission Expires: ________________________