Medical Power of Attorney Document for Oregon State

Oregon Medical Power of Attorney Template

This Medical Power of Attorney is a legal document that allows an individual (the "Principal") to designate another person (the "Agent") to make healthcare decisions on the Principal's behalf if they are unable to do so. This document is created in compliance with the relevant state-specific laws, particularly the Oregon Revised Statutes.

Principal's Information

Full Name: ___________________________

Date of Birth: ___________________________

Address: ___________________________

Agent's Information

Full Name: ___________________________

Relationship to Principal: ___________________________

Primary Phone Number: ___________________________

Alternate Phone Number (optional): ___________________________

Address: ___________________________

Alternate Agent (Optional)

If the primary Agent is unwilling, unable, or ineligible to act as your Agent, an alternate Agent can be named who will have the same authority to make health care decisions on your behalf.

Full Name: ___________________________

Relationship to Principal: ___________________________

Primary Phone Number: ___________________________

Address: ___________________________

Authority of the Agent

The Principal grants the Agent the following powers:

• To consent, refuse, or withdraw consent to any type of medical care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
• To make decisions regarding the Principal’s admission to or discharge from medical facilities.
• To have access to the Principal’s medical records and to discuss them with healthcare providers.
• To make decisions about the Principal’s participation in medical research or clinical trials.

Limitations on Agent’s Authority

The Principal may specify any limitations on the Agent’s authority to make healthcare decisions:

________________________________________________________________

________________________________________________________________

Effective Date and Duration

This Medical Power of Attorney becomes effective immediately and remains in effect until the Principal’s death, unless the Principal specifies differently here:

________________________________________________________________

Signature

This document must be signed by the Principal in the presence of two witnesses, who must also sign the document, affirming that the Principal appears to understand the nature of the document and is free from duress or undue influence.

Principal's Signature: ___________________________ Date: ________________

Witness #1 Signature: ___________________________ Date: ________________

Print Name: ____________________________________

Witness #2 Signature: ___________________________ Date: ________________

Print Name: ____________________________________

This template is provided as a general guide and should be reviewed by an attorney to ensure it meets all legal requirements in Oregon and reflects the Principal’s wishes accurately.