Utah Medical Power of Attorney
This document empowers a trusted individual to make healthcare decisions on your behalf should you become unable to do so. It is crafted in accordance with the provisions of the Utah Advance Health Care Directive Act.
Principal Information:
Name: ___________________________
Address: _________________________
City: ____________________________
State: Utah
Zip Code: ________________________
Date of Birth: ____________________
Phone Number: ____________________
Agent Information:
Name: ___________________________
Address: _________________________
City: ____________________________
State: Utah
Zip Code: ________________________
Phone Number: ____________________
Email Address: ___________________
Alternate Agent Information (Optional):
Name: ___________________________
Address: _________________________
City: ____________________________
State: Utah
Zip Code: ________________________
Phone Number: ____________________
Email Address: ___________________
I hereby appoint the above-named agent to act as my attorney-in-fact to make health care decisions on my behalf as authorized in this document. In the event the above-named agent is unable, unwilling, or unavailable to act as my agent, the above-named alternate agent shall serve in that capacity.
Directive:
I grant my agent full power to make decisions for me about my health care, including the power to:
- Consent, refuse, or withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
- Select or discharge health care providers and institutions.
- Access my medical records.
- Make decisions about organ donation, autopsy, and disposition of my body.
Signatures:
This document must be signed by the principal, the agent, and an adult witness who is not related by blood or marriage to the principal and does not stand to inherit any part of the principal’s estate.
Principal Signature: ___________________________ Date: _________
Agent Signature: _____________________________ Date: _________
Alternate Agent Signature (if applicable): ___________________________ Date: _________
Witness Signature: ___________________________ Date: _________
State of Utah Acknowledgment:
This section is to be completed by a Notary Public.
State of Utah, County of ____________
On the ____ day of ___________, 20__, before me, _____________________, a Notary Public, personally appeared ________________, known to me (or satisfactorily proven) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged that he/she/they executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
Notary Public: _________________________
My Commission Expires: _________________