Colorado Medical Power of Attorney Form
If you want to grant a person the legal power to be your health care representative, you have to use this form.
DownloadExtracted Text for Proper Search
MEDICAL DURABLE POWER OF ATTORNEY FOR HEALTHCARE DECISIONS
I. APPOINTMENT OF AGENT AND
ALTERNATES
I, ____________________________________ ,
Declarant, hereby appoint:
Name of Agent
Agent’s Best Contact Telephone Number
Agent’s email or alternative telephone number
Agent’s home address
as my Agent to make and communicate my healthcare
decisions when I cannot. This gives my Agent the
power to consent to, or refuse, or stop any healthc are,
treatment, service, or diagnostic procedure. My Age nt
also has the authority to talk with healthcare pers onnel,
get information, and sign forms as necessary to car ry out
those decisions.
If the person named above is not available or is un able
to continue as my Agent, then I appoint the followi ng
person(s) to serve in the order listed below.
Name of Alternate Agent #1
Agent’s Best Contact Telephone Number
Agent’s email or alternative telephone number
Agent’s home address
Name of Alternate Agent #2
Agent’s Best Contact Telephone Number
Agent’s email or alternative telephone number
Agent’s home address
II. WHEN AGENT’S POWERS BEGIN
By this document, I intend to create a Medical Dura ble
Power of Attorney which shall take effect either
( initial
one )
:
______ ( Initials) Immediately upon my signature.
______ ( Initials) When my physician or other qualified
medical professional has determined that I am unabl e to
make my or express my own decisions, and for as lon g
as I am unable to make or express my own decisions.
III. INSTRUCTIONS TO AGENT
My Agent shall make healthcare decisions as I direc t
below, or as I make known to him or her in some oth er
way. If I have not expressed a choice about the dec ision
or healthcare in question, my Agent shall base his or her
decisions on what he or she, in consultation with m y
healthcare providers, determines is in my best inte rest. I
also request that my Agent, to the extent possible,
consult me on the decisions and make every effort t o
enable my understanding and find out my preferences .
State here any desires concerning life-sustaining
procedures, treatment, general care and services,
including any special provisions or limitations:
My signature below indicates that I understand the
purpose and effect of this document:
Signature of Declarant Date
Pursuant to Colorado Revised Statute 15-14.503–509 1
ADDENDUM TO MEDICAL DURABLE POWER OF ATTORNEY – RECOMMENDED, NOT REQUIRED
1. Signature of the Appointed Agent
Although not required by Colorado law, my signature
below indicates that I have been informed of my
appointment as a Healthcare Agent under Medical
Durable Power of Attorney for ( name of Declarant)
.
I accept the responsibilities of that appointment, and I
have discussed with the Declarant his or her wishes and
preferences for medical care in the event that he o r she
cannot speak for him- or herself.
I understand that I am always to act in accordance with
his or her wishes, not my own, and that I have full
authority to speak with his or her healthcare provi ders,
examine healthcare records, and sign documents in o rder
to carry out those wishes. I also understand that m y
authority as a Healthcare Agent is only in effect w hen
the Declarant is unable to make his or her own deci sions
and that it automatically expires at his or her dea th.
If I am an alternate Agent, I understand that my
responsibilities and powers will only take effect i f the
primary Agent is unable or unwilling to serve.
Primary Agent’s Signature
Printed Name
Date
Alternate Agent #1 Signature
Printed Name
Date
Alternate Agent #2 Signature
Printed Name
Date
2. Signature of Witnesses and Notary
The signature of two witnesses and a notary seal ar e not
required by Colorado law for proper execution of a
Medical Durable Power of Attorney; however, they ma y
make the document more acceptable in other states.
This document was signed by ( name of Declarant)
in our presence, and we, in the presence of each ot her,
and at the Declarant’s request, have signed our nam es
below as witnesses. We declare that, at the time th e
Declarant signed this document, we believe that he or
she was of sound mind and under no pressure or undu e
influence. We are at least eighteen (18) years old.
Signature of Witness
Printed Name
Address
Signature of Witness
Printed Name
Address
Notary Seal (optional )
State of ___________________________
County of
}
SUBSCRIBED and sworn to before me by
,
the Declarant,
and
and
witnesses, as the voluntary act and deed of the Dec larant
this day of
, 20 .
Notary Public
My commission expires:
Pursuant to Colorado Revised Statute 15-14.503–509 2
If you want to remove Colorado Medical Power of Attorney Form from this website please contact us providing the reasons together with this url: https://formsarchive.com/colorado-medical-power-of-attorney-form/