This Minnesota Medical Power of Attorney is crafted to comply with the specific requirements set forth by the Minnesota Statutes. It grants authority to an Agent to make healthcare decisions on behalf of the Principal, in accordance with state laws. This document should only be used by residents of Minnesota or for medical decisions that will be carried out in the state of Minnesota.
Principal's Information:
- Full Name: ___________________________
- Address: ______________________________
- City: _______________ State: MN Zip: _________
- Date of Birth: ___________
Agent's Information:
- Full Name: ___________________________
- Relationship to Principal: _______________
- Primary Phone: _________________________
- Alternate Phone: ________________________
- Email Address: __________________________
Successor Agent's Information (Optional):
- Full Name: ___________________________
- Relationship to Principal: _______________
- Primary Phone: _________________________
- Alternate Phone: ________________________
- Email Address: __________________________
In the event that my first-choice Agent is unable, unwilling, or unavailable to serve as my medical decision-maker, my Successor Agent shall assume all duties as outlined in this document.
Authority Granted:
- To consent, refuse, or withdraw consent for any type of medical care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
- To access my medical records and disclose them to others as necessary to ensure the Healthcare decisions made are in my best interest.
- To make decisions regarding my admission to or discharge from a healthcare facility, including hospitals, nursing homes, or assisted living facilities.
- To discuss my condition and treatment options with healthcare providers, including the possibility of palliative care and hospice.
Special Instructions (if any):
- ________________________________________________________________
- ________________________________________________________________
By signing below, I affirm that I understand the contents of this document and the authority I grant herein. I sign this document voluntarily and under no duress.
Principal's Signature: _____________________________ Date: ____________
Agent's Signature: _______________________________ Date: ____________
Successor Agent's Signature (if applicable): __________________ Date: ____________
Witness's Signature: _____________________________ Date: ____________
This document must be signed in the presence of a witness who is not the agent or successor agent. The witness affirms that the principal appears to understand the nature and significance of the document and is free from duress or undue influence at the time of signing.
