Alaska Medical Power of Attorney
This Alaska Medical Power of Attorney is a legal document that allows an individual (referred to as the "Principal") to designate another person (referred to as the "Agent") to make health care decisions on the Principal's behalf if the Principal is unable to make such decisions. This document is pursuant to the Alaska Statutes, specifically under the Alaska Statute §13.26.332-346.
By completing this document, the Principal ensures that their health care wishes are known and can be carried out during times they are not able to communicate their wishes directly.
Principal Information
Full Name: ________________________
Address: ________________________
City: ________________________
State: Alaska
Zip Code: ________________________
Date of Birth: ________________________
Agent Information
Full Name of Agent: ________________________
Address: ________________________
City: ________________________
State: ________________________
Zip Code: ________________________
Alternate Phone Number: ________________________
Powers Granted
This document grants the Agent the following powers, subject to any limitations specified:
- To consent to or refuse any medical treatment on behalf of the Principal.
- To access the Principal's medical records necessary for the Agent to make informed decisions regarding the Principal's health care.
- To communicate with health care providers about the Principal's condition and treatment options.
- To make decisions regarding the Principal's admission to or discharge from health care facilities.
Limitations
Specific Limitations: ________________________
Duration
This Medical Power of Attorney will become effective on the date it is signed and remain in effect indefinitely unless a specific expiration date is set forth below.
Expiration Date (if any): ________________________
Signatures
Principal's Signature: ________________________ Date: ________________________
Agent's Signature: ________________________ Date: ________________________
Witnesses (if required by law)
This document must be signed in the presence of two witnesses who are not the agent or related to the principal by blood or marriage. The witnesses affirm that the principal appears to be of sound mind and under no duress, fraud, or undue influence at the time this document is signed.
Witness 1 Signature: ________________________ Date: ________________________
Witness 2 Signature: ________________________ Date: ________________________
Notarization (if required)
This document may also be notarized to add an extra layer of legal validity and protection. Notarization is optional but recommended.
Notary Public Signature: ________________________ Date: ________________________
Seal: