Michigan Medical Power of Attorney
This Michigan Medical Power of Attorney is a legal document that allows you, the principal, to designate an individual, known as your patient advocate, to make health care decisions on your behalf should you become unable to make them yourself. This document is governed by the laws of the State of Michigan, particularly the Michigan Durable Power of Attorney for Health Care Act.
Part 1: Principal Information
Full Name: ________________________
Date of Birth: _____________________
Address: __________________________
City: _____________________________
State: Michigan
Zip Code: _________________________
Telephone Number: __________________
Part 2: Patient Advocate Designation
I, ____________________ [Principal’s Full Name], hereby appoint:
Full Name: ________________________
Relationship to Principal: ___________
Address: __________________________
City: _____________________________
State: ____________________________
Zip Code: _________________________
Alternate Telephone Number: __________________
as my patient advocate to make health care decisions for me as authorized in this document.
Part 3: Powers of Patient Advocate
The patient advocate is authorized to make all forms of health care decisions on my behalf that I could make personally if I were able, including but not limited to:
- Consent to or refuse any treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
- Make decisions about withdrawing or withholding life-sustaining treatment.
- Have access to medical records and information to the same extent I would have access.
This authorization does not include the power to consent to voluntary euthanasia, mercy killing, or any act that will end my life other than to allow me to die naturally with dignity.
Part 4: Terms and Conditions
This power of attorney will become effective upon the determination that I am unable to participate in medical treatment decisions. My patient advocate shall not make medical treatment decisions unless I am unable to participate in medical treatment decisions, as determined by my attending physician and another physician or licensed psychologist.
Part 5: Signatures
I understand that this designation is voluntary and that I may revoke it at any time by a signed, dated, and witnessed writing or by orally informing my healthcare provider.
Principal's Signature: ________________________ Date: ________________
Patient Advocate's Signature: ________________________ Date: ________________
Witnesses (2 required):
1. Signature: ________________________ Date: ________________
Print Name: ________________________
2. Signature: ________________________ Date: ________________
Print Name: ________________________
In accordance with the Michigan Durable Power of Attorney for Health Care Act, this document must be signed by the principal, the patient advocate, and two witnesses. The witnesses to this power of attorney must not be the patient advocate, the patient's spouse, parent, child, grandchild, sibling, presumptive heir, known devisee, attending physician, or employee of a life or health insurance provider for the patient. Furthermore, the witnesses must not be financially responsible for the patient's medical care.