Free Template for Medical Directives and Healthcare Power of Attorney in Washington, D.C.

Planning for your future healthcare needs is one of the most important decisions you can make. Whether you’re preparing for unforeseen medical circumstances or ensuring that your wishes are honored in case of incapacitation, having a medical directive and healthcare power of attorney (POA) in place is essential. Below is a comprehensive template provided by DC Mobile Notary that you can use to create these critical documents.

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Medical Directive and Healthcare Power of Attorney Template

Full Legal Name:
[Your Full Name]

Address:
[Your Full Address]

Phone Number:
[Your Phone Number]

Date of Birth:
[Your Date of Birth]

Email Address:
[Your Email Address]

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Section 1: Appointment of Healthcare Agent

I, [Your Full Name], hereby appoint the following individual as my healthcare agent (proxy) to make medical decisions on my behalf if I am unable to communicate my preferences:

Primary Healthcare Agent:

• Name: [Full Name of Healthcare Agent]
• Address: [Agent’s Address]
• Phone Number: [Agent’s Phone Number]
• Email: [Agent’s Email Address]

Alternate Healthcare Agent (if primary is unavailable):

• Name: [Full Name of Alternate Agent]
• Address: [Alternate Agent’s Address]
• Phone Number: [Alternate Agent’s Phone Number]
• Email: [Alternate Agent’s Email Address]

Initial Here if you agree with this appointment: ________

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Section 2: Healthcare Preferences

2.1 Life-Sustaining Treatment

In the event that I am in a terminal condition or permanently unconscious, I direct that life-sustaining treatments (such as mechanical ventilation, dialysis, or artificial nutrition) be:

• Provided to prolong my life.
  Initial Here: ________
• Withheld or withdrawn to allow for a natural death.
  Initial Here: ________

2.2 Do Not Resuscitate (DNR) Order

I request the following in the event that my heart stops or I stop breathing:

• I do want to be resuscitated.
  Initial Here: ________
• I do not want to be resuscitated (DNR order).
  Initial Here: ________

2.3 Pain Management and Palliative Care

I request that I receive appropriate pain management and comfort care in all circumstances, even if it may hasten my death:

• I want pain management to prioritize my comfort.
  Initial Here: ________
• I do not want aggressive pain management.
  Initial Here: ________

2.4 Organ Donation

Upon my death, I request the following regarding organ and tissue donation:

• I consent to organ and tissue donation for transplant.
  Initial Here: ________
• I consent to organ and tissue donation for medical research.
  Initial Here: ________
• I do not consent to organ and tissue donation.
  Initial Here: ________

2.5 Religious or Cultural Preferences

Please list any religious or cultural considerations you would like your healthcare agent and providers to be aware of:

• Yes, I have religious or cultural preferences.
  Please specify: _______________________________
  Initial Here: ________
• No, I have no specific religious or cultural preferences.
  Initial Here: ________

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Section 3: Appointment of Guardian (if applicable)

If a court determines that a guardian should be appointed for me, I request the following individual to be considered:

• Guardian’s Name: [Full Name of Guardian]
• Address: [Guardian’s Address]
• Phone Number: [Guardian’s Phone Number]

Initial Here if you agree with this appointment: ________

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Section 4: Revocation of Previous Directives

I hereby revoke any and all prior medical directives and healthcare power of attorney documents I have executed.

Initial Here if you agree: ________

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Section 5: Signature and Witnesses

This document is signed willingly and under no duress. I understand the nature and effect of this document and sign it voluntarily.

Your Signature: _______________________________
Date: _______________________________

Witness 1

Name of Witness 1: _______________________________
Signature of Witness 1: _______________________________
Date: _______________________________
Address: _______________________________

Witness 2

Name of Witness 2: _______________________________
Signature of Witness 2: _______________________________
Date: _______________________________
Address: _______________________________

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Section 6: Notarization (Recommended)

To further ensure the validity and recognition of this document, it is recommended that you have this document notarized. Contact DC Mobile Notary for convenient mobile notary services.

State of [State Name]
County of [County Name]

On this [Day] of [Month], [Year], before me, [Notary Public's Name], personally appeared [Your Full Name], who proved to me through satisfactory evidence of identification to be the individual whose name is signed on this document.

Notary Public’s Signature: _______________________________
Commission Expiration Date: _______________________________
Notary Seal: _______________________________

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How to Use This Template

1. Fill in your personal information and healthcare preferences: Be sure to clearly state your medical preferences, healthcare agent’s information, and other critical details.
2. Sign the document in the presence of two witnesses: These witnesses should not be your healthcare agent or alternate agent.
3. Notarize your document: Although not always required, having this document notarized adds an extra layer of legal protection. You can use DC Mobile Notary for mobile notarization services.
4. Distribute copies: Provide copies to your healthcare agent, alternate agent, and any healthcare providers responsible for your care. Keep a copy for yourself in a safe place.

Why Choose DC Mobile Notary?

At DC Mobile Notary, we provide reliable and professional notarization services to ensure that your medical directives and healthcare POAs are legally binding and easily accessible. Our mobile notary services bring convenience to your home, office, or healthcare facility.

• Mobile and Convenient: We come to you.
• Experienced: Our notaries are experienced with healthcare documents.
• Confidential and Reliable: Your privacy is our priority.

Disclaimer

This template is intended for informational purposes only and does not constitute legal advice. It is strongly recommended that you consult with an attorney to ensure compliance with all applicable laws in Washington, D.C., and that your documents reflect your specific legal and personal preferences. DC Mobile Notary is not responsible for any legal outcomes resulting from the use of this template.

Contact DC Mobile Notary

For professional and convenient notarization of your medical directive and healthcare POA, contact us today:

• Phone: +1 (202) 247 0837
• Email: support@dcmobilenotary.com
• Website: https://www.dcmobilenotary.com/

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