This Medical Power of Attorney is established in accordance with the Rhode Island Health Care Power of Attorney Act (Chapter 23-4.10) and empowers the named individual to make healthcare decisions on the principal’s behalf when they are unable to do so. This document is a powerful tool enabling your agent to ensure that your healthcare preferences are considered and respected.
Rhode Island Medical Power of Attorney
Principal’s Information:
- Full Name: ___________________________
- Date of Birth: ________________________
- Address: _____________________________
- City: _______________________________
- State: Rhode Island
- Zip Code: ___________________________
Agent's Information:
- Full Name: ___________________________
- Relationship to Principal: _____________
- Primary Phone: ______________________
- Alternate Phone: ____________________
- Email Address: ______________________
- Address: _____________________________
- City: _______________________________
- State: _____________________________
- Zip Code: ___________________________
Alternate Agent’s Information (Optional):
- Full Name: ___________________________
- Relationship to Principal: _____________
- Primary Phone: ______________________
- Alternate Phone: ____________________
- Email Address: ______________________
- Address: _____________________________
- City: _______________________________
- State: _____________________________
- Zip Code: ___________________________
By signing this document, the principal nominates the aforementioned agent to make health care decisions in accordance with their wishes, religious and moral beliefs, and in the best interest when the principal is not able to make such decisions. This includes decisions concerning medical treatment, surgical procedures, life support, and the principal’s participation in medical research if necessary.
Special Instructions:
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This Medical Power of Attorney does not authorize the agent to make any financial decisions on behalf of the principal.
Signatures:
This document must be signed by the principal, the chosen agent, and a witness to be legally binding. The witness should not be the agent, the principal’s healthcare provider, or an employee of the healthcare provider.
Principal’s Signature: ___________________________ Date: ____________
Agent’s Signature: ___________________________ Date: ____________
Alternate Agent’s Signature (If Applicable): ___________________________ Date: ____________
Witness’s Signature: ___________________________ Date: ____________
Notarization (If Required):
In some cases, it might be required to have this document notarized. Please consult with a legal advisor to understand if this step is necessary for your document to be considered valid and enforceable.
