Arkansas Medical Power of Attorney Template
This Medical Power of Attorney is a legal document that allows you to appoint someone to make healthcare decisions on your behalf if you become unable to do so. This document is governed by the laws of the State of Arkansas.
Principal Information:
- Name: ___________________________________________
- Address: _________________________________________
- City: ____________________________________________
- State: Arkansas
- Zip Code: ______________________________________
- Date of Birth: ___________________________________
Agent Information:
- Name: ___________________________________________
- Address: _________________________________________
- City: ____________________________________________
- State: ___________________________________________
- Zip Code: ______________________________________
- Phone Number: ___________________________________
Alternate Agent Information:
- Name: ___________________________________________
- Address: _________________________________________
- City: ____________________________________________
- State: ___________________________________________
- Zip Code: ______________________________________
- Phone Number: ___________________________________
Effective Date: This Medical Power of Attorney becomes effective when I am unable to make my own healthcare decisions.
Healthcare Decisions Include:
- Choosing healthcare providers.
- Deciding on medical treatments.
- Accessing medical records.
- Making decisions about life-sustaining treatments.
Signature: I, the undersigned, hereby appoint the above-named agent to make healthcare decisions on my behalf.
Principal Signature: _______________________________
Date: ____________________________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to the principal or the agent.
- Witness 1 Name: ________________________________
- Witness 1 Signature: ___________________________
- Date: _________________________________________
- Witness 2 Name: ________________________________
- Witness 2 Signature: ___________________________
- Date: _________________________________________
This Medical Power of Attorney is valid under Arkansas law. Ensure that all information is filled out completely and accurately.