Fillable Medical Power of Attorney Form for Utah State

Utah Medical Power of Attorney

This document grants power of attorney for medical decisions in the state of Utah, in accordance with the Utah Advance Health Care Directive Act. It is designed to allow you to appoint someone you trust to make health care decisions on your behalf, should you become unable to make them yourself.

Principal’s Information:

• Full Name: _____________________________________________
• Address: _______________________________________________
• City: _______________________ State: UT Zip: ____________
• Phone Number: ________________________________________
• Date of Birth: _________________________________________

Agent’s Information:

• Full Name: _____________________________________________
• Address: _______________________________________________
• City: _______________________ State: UT Zip: ____________
• Phone Number: ________________________________________

Alternate Agent’s Information (Optional):

• Full Name: _____________________________________________
• Address: _______________________________________________
• City: _______________________ State: UT Zip: ____________
• Phone Number: ________________________________________

This Medical Power of Attorney becomes effective when I, the principal, am unable to make my own health care decisions as verified by a medical professional. My agent will have the authority to make all healthcare decisions on my behalf that I could make if capable, except as I may otherwise limit in this document.

Special Instructions:

______________________________________________________________________________________

______________________________________________________________________________________

Signatures:

This document must be signed by the principal, in the presence of a notary public or two adult witnesses, neither of whom is the agent or alternate agent. Witnesses must not be related to the principal by blood or marriage and must not stand to inherit from the principal’s estate.

Principal’s Signature: ___________________________ Date: ___________

Agent’s Signature: _____________________________ Date: ___________

Alternate Agent’s Signature: ____________________ Date: ___________ (Optional)

Notary Public or Witnesses’ Acknowledgment:

1. Notary Public or First Witness Signature: __________________________________ Date: ___________
2. Second Witness Signature (if applicable): _________________________________ Date: ___________

This document is not valid unless it is signed by the required parties. By signing, all parties acknowledge that they understand the document and agree to its terms.