Delaware Medical Power of Attorney
This Delaware Medical Power of Attorney allows you to appoint someone to make medical decisions on your behalf if you become unable to do so. This document is governed by Delaware state laws, specifically Title 16, Chapter 2501 of the Delaware Code.
Principal Information:
- Name: ____________________________
- Address: ____________________________
- City, State, Zip: ____________________________
- Date of Birth: ____________________________
Agent Information:
- Name: ____________________________
- Address: ____________________________
- City, State, Zip: ____________________________
- Phone Number: ____________________________
Effective Date: This Medical Power of Attorney becomes effective when I am unable to make my own medical decisions, as determined by my attending physician.
Agent’s Authority: My agent shall have the authority to make medical 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.
- Choose healthcare providers and facilities.
Limitations: Any limitations on my agent's authority are as follows:
____________________________________________________________________
____________________________________________________________________
Signature of Principal: ____________________________
Date: ____________________________
Witness Statement: I hereby declare that I am not related to the Principal by blood or marriage, and I am not entitled to any portion of the Principal's estate.
Witness Signature: ____________________________
Date: ____________________________
Notary Public:
State of Delaware
County of ____________________________
Subscribed and sworn before me this _____ day of ____________, 20__.
Notary Signature: ____________________________
My Commission Expires: ____________________________