Fillable Medical Power of Attorney Document for Utah State

The Utah Medical Power of Attorney form is a legal document that allows individuals to appoint someone they trust to make healthcare decisions on their behalf if they are unable to do so themselves. This important form ensures that personal health care preferences are respected and followed during critical times. For those ready to take this step, simply click the button below to begin filling out the form.

Get Form Here

Considering the intricacies of healthcare decisions, especially during times of incapacity, the Utah Medical Power of Attorney (MPOA) form serves as a critical legal document. This form allows individuals to appoint a trusted person, known as a healthcare agent, to make healthcare decisions on their behalf when they are unable to do so themselves. Whether due to illness, injury, or incapacity, having an MPOA in place ensures that one’s healthcare wishes are respected and followed. It covers a broad scope of medical decisions, ranging from routine to life-sustaining treatments. Understanding its provisions, how to appoint an agent, and the circumstances under which it becomes effective provides peace of mind not only to the individual but also to their loved ones. This essential forward-thinking step ensures that healthcare preferences are clearly communicated and legally documented, simplifying the decision-making process for all involved during challenging times.

Contents

Utah Medical Power of Attorney Example

Utah Medical Power of Attorney

This Medical Power of Attorney is established under Utah Code Title 75 — Utah Uniform Probate Code, Chapter 5 — Adult Health Care Consent Act, allowing an individual (hereinafter referred to as the "Principal") to designate another person (referred to as the "Agent") to make health care decisions on the Principal’s behalf in the event the Principal becomes unable to make such decisions.

Principal Information

Full Name: ____________________________

Date of Birth: ____________________________

Primary Address: ____________________________

City: ____________________________

State: UT

Zip Code: ____________________________

Phone Number: ____________________________

Agent Information

Full Name: ____________________________

Relationship to Principal: ____________________________

Primary Address: ____________________________

City: ____________________________

State: ____________________________

Zip Code: ____________________________

Phone Number: ____________________________

Alternate Agent Information (Optional)

If the Agent is unable or unwilling to serve, the Principal designates the following individual as an alternate to the Agent:

Full Name: ____________________________

Relationship to Principal: ____________________________

Primary Address: ____________________________

City: ____________________________

State: ____________________________

Zip Code: ____________________________

Phone Number: ____________________________

Scope of Authority Granted to the Agent

The Principal grants the Agent the following powers, subject to any specific limitations or additions provided by the Principal:

Make health care decisions on the Principal’s behalf as authorized by this document, including the power to consent, refuse consent, or withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
Access the Principal’s medical records necessary to make informed decisions about the Principal's health care.
Communicate with health care providers concerning the Principal's health care.
Make decisions regarding the Principal's admission to, or discharge from, health care facilities.

Special Instructions/Limitations

The Principal may specify any limitations or special instructions to be followed by the Agent:

________________________________________________________________________________________________________

Signatures

This document becomes effective upon the incapacity of the Principal, as determined by a physician. It will remain in effect until the Principal's death or upon revocation by the Principal.

Principal's Signature: ____________________________ Date: ____________________________

Agent's Signature: ____________________________ Date: ____________________________

Alternate Agent's Signature (if applicable): ____________________________ Date: ____________________________

Witness Statement

For the Medical Power of Attorney to be legally binding, it must be signed in the presence of two witnesses, who also must sign below, affirming that:

The Principal appeared to be of sound mind and free from duress at the time of signing the document.
Neither witness is the Principal's health care provider, an employee of the health care provider, or have any claim against the Principal’s estate.

Witness 1 Signature: ____________________________ Date: ____________________________

Witness 2 Signature: ____________________________ Date: ____________________________

This document is not a substitute for a Living Will and does not affect the distribution of an individual’s estate upon death.

⇓ PDF File

Form Overview

Fact	Description
Definition	The Utah Medical Power of Attorney form is a legal document empowering someone to make healthcare decisions on behalf of the person completing the form, should they become unable to communicate or make decisions for themselves.
Governing Laws	The form is governed by the Utah Uniform Power of Attorney Act, specifically Title 75, Chapter 9, Part 2 of the Utah Code.
Principal Requirements	The individual creating the document, known as the principal, must be of sound mind and at least 18 years old at the time of document execution.
Agent Qualifications	The designated agent or attorney-in-fact must be an adult or an emancipated minor, with the principal's trust to act in their best interest, but cannot be the healthcare provider or residential care provider for the principal.
Execution Requirements	It must be signed by the principal and either notarized or witnessed by two adults, who are not related by blood, marriage, legalized by the state, or proposed to inherit upon the death of the principal.
Durability	This power of attorney remains in effect even if the principal becomes incapacitated, making it durable, unless it expressly states a termination date or event.
Revocation	The principal may revoke the document at any time, as long as they are competent, by notifying the agent in writing or by executing a new medical power of attorney form.

Documents used along the form

When preparing for future healthcare decisions, individuals often focus on the Medical Power of Attorney form, especially within Utah's legal landscape. This document plays a crucial role, allowing a designated agent to make healthcare decisions on one’s behalf should they become unable to do so themselves. However, this crucial document is frequently accompanied by other legal forms and documents, which together form a comprehensive healthcare directive plan. These additional documents cater to a variety of needs and scenarios, ensuring one’s healthcare wishes are fully documented and legally recognized.

Living Will: A Living Will, or advance healthcare directive, specifies one’s preferences regarding medical treatment if they become incapacitated or otherwise unable to communicate their wishes. This document complements the Medical Power of Attorney by providing clear instructions on life-sustaining treatments, palliative care, and end-of-life wishes, ensuring decisions align with the individual's values and preferences.
Do Not Resuscitate (DNR) Order: This critical document specifically addresses whether an individual wants resuscitation measures to be taken if their breathing stops or if their heart stops beating. Unlike the broader scope of a Living Will, a DNR focuses solely on this aspect of emergency medical care, guiding first responders and healthcare professionals in a moment of crisis.
POST Form (Physician Orders for Life-Sustaining Treatment): Similar to a DNR, the POST form goes further by providing detailed medical orders about the extent of treatment an individual desires in various scenarios, including resuscitation, hospitalization, intubation, and use of antibiotics. It’s intended for persons with serious health conditions and provides a higher level of specificity than a Living Will.
Designation of Primary Physician: This document is where one names their preferred primary care physician. In situations where medical decisions need to be made, and the appointed power of attorney needs consultation, having a designated primary physician ensures that there is a go-to medical professional familiar with the patient’s medical history and healthcare philosophy.

In crafting a robust healthcare directive, each of these documents serves an essential function, providing a comprehensive framework that addresses a wide range of medical decisions and preferences. Together with the Medical Power of Attorney, they ensure one’s healthcare wishes are respected and followed, offering peace of mind to both the individual and their loved ones. It's a testament to the importance of foresight and the deep value we place on personal autonomy and dignity in healthcare decisions.

Consider Some Other Medical Power of Attorney Templates for Specific States

Maryland Power of Attorney Form - Emergency situations where you're unable to consent to treatment underscore the importance of having a Medical Power of Attorney in place.

What Is Power of Attorney in a Will - This form is a key element in a comprehensive healthcare plan, designed to keep you covered in emergencies and unforeseen circumstances.