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FREE TEMPLATE / PERSONAL, FAMILY AND LEGAL

Medical Power of Attorney (United States)

Names a health care agent and an alternate to make medical decisions for an adult in any US state when a doctor finds they cannot decide for themselves. It records end-of-life and organ donation wishes, lets the agent see medical records under HIPAA, and is signed before two witnesses and a notary as the state requires.

For the United States.

Download the free PDF

This page lists how to sign it in the United States. See how it is signed

First page of the Medical Power of Attorney (United States) template
PDF, 4 pages, 18 KB
THE DOCUMENT

What it covers

The template has 12 parts.

  1. My health care agent
  2. Alternate agent
  3. When my agent may act
  4. My agent's authority
  5. My wishes about end-of-life care
  6. HIPAA authorization
  7. Organ and tissue donation
  8. Other instructions
  9. Earlier documents and copies
  10. Signature of the principal
  11. Statement of witnesses
  12. Notary acknowledgment
BEFORE YOU START

What you will be asked

Have these details ready. The template needs them before anyone signs.

  • What is your full legal name?
  • What is your date of birth?
  • What is your home address?
  • In which state do you live?
  • Who should make medical decisions for you if you cannot? Give their full name, relationship, address and phone number.
  • Who should decide if that person is not available or willing? Give the same details, or say none.Optional
  • What are your wishes about treatment to keep you alive if you are terminally ill or permanently unconscious?
  • Do you want to donate organs or tissue after you die? Say yes, name particular organs, or say no.
  • Do you have any other instructions, such as religious wishes or a preferred hospital? Say none if not.Optional
THE PEOPLE

Who signs

Everyone the template names, and what each one does.

  • PrincipalSigns
  • First witnessWitness
  • Second witnessWitness
  • Notary publicNotary
SIGNING RULES

How it is signed in the United States

The rules for a power of attorney for health care depend on where it is signed. Laws change, so check the sources before anyone signs.

United States

Print and sign in ink

Print it and sign it in ink in front of two witnesses, who sign it too.

Steps

  1. Print the document.
  2. Sign it in front of two qualified adult witnesses who sign too, or before a notary where your state allows.
  3. Give copies to your agent, your doctor and your hospital.

What the law asks for

E-signature
Only in some casesHealth care powers of attorney follow each state's own form and witness rules. Sign prepares it to print.
Witnesses
TwoMost states need two adult witnesses or a notary. A witness is usually not the agent and not the principal's health care provider.
Notary
OptionalIn many states a notary can take the place of the two witnesses.
Remote signing
Not confirmed
Registration
Not neededGive copies to the agent and the doctor.
Stamp duty
Not needed

Where the rules differ

Signing rules by state in the United States
StateHow it is signedE-signatureWitnessesNotaryRegistrationStamp duty
CaliforniaPrint and sign in inkOnly in some casesTwoOptionalNot neededNot needed

California accepts an electronic advance health care directive only when it is acknowledged before a notary and the digital signature meets Probate Code 4673(b).

FloridaPrint and sign in inkOnly in some casesTwoNot neededNot neededNot needed
New YorkPrint and sign in inkOnly in some casesTwoNot neededNot neededNot needed

New York uses a health care proxy.

TexasPrint and sign in inkOnly in some casesTwoOptionalNot neededNot needed

Texas has a statutory medical power of attorney form.

Sources

Checked October 25, 2026 against these sources.

QUESTIONS

Common questions

Answers from the signing rules on this page.

Can the medical power of attorney be signed electronically in the United States?

Only in some cases in the United States. Health care powers of attorney follow each state's own form and witness rules. Sign prepares it to print.

How many witnesses does the medical power of attorney need in the United States?

Two witnesses. Most states need two adult witnesses or a notary. A witness is usually not the agent and not the principal's health care provider.

Does the medical power of attorney need a notary in the United States?

No. A notary is optional. In many states a notary can take the place of the two witnesses.

Does the medical power of attorney need to be registered in the United States?

No. It is not registered. Give copies to the agent and the doctor.

Is stamp duty due on the medical power of attorney in the United States?

No stamp duty is due.

Can the medical power of attorney be signed electronically in the United States?

It depends on the state. Of the 4 states on this page, 4 accept it only in some cases.

How many witnesses does the medical power of attorney need in the United States?

Two in each of the 4 states on this page.

Does the medical power of attorney need a notary in the United States?

No, in all 4 states on this page.

Does the medical power of attorney need to be registered in the United States?

No, in all 4 states on this page.

Is stamp duty due on the medical power of attorney in the United States?

No, in all 4 states on this page.

THE RIGHT TEMPLATE

Where it fits

For an adult in any US state. It covers health care decisions only, so use the durable power of attorney for money and property. Many states have their own statutory advance directive forms and witness rules, and some call this document a health care proxy or health care power of attorney.

A CAREFUL CHECK

Before you rely on it

Original Centilio wording, not legal advice. A health care power of attorney with a HIPAA authorization that follows 45 CFR 164.508. Many states have their own statutory advance directive forms and witness rules: some bar relatives, heirs or anyone paying for the principal's care from witnessing, some require a notary or accept one in place of witnesses, Texas requires wording substantially like its statutory form, and New York uses a health care proxy under Public Health Law article 29-C. Some states limit an agent's decisions about mental health treatment, life-sustaining treatment during pregnancy or tube feeding. It is not a do-not-resuscitate order or POLST, which a doctor signs. See a lawyer or your doctor where your state's own form is required or your wishes are complex.