North Dakota Medical Power of Attorney
This Medical Power of Attorney is made under the North Dakota Century Code, Section 23-06.5, also known as the "Uniform Health-Care Decisions Act." It allows you, the "Principal," to designate another person, known as an "Agent," to make health-care decisions on your behalf if you are unable to communicate your wishes. It is a legally binding document once all required parties sign it and it complies with all relevant North Dakota state laws.
Principal Information
- Full Name: ____________
- Date of Birth: ____________
- Address: ____________, ____________, North Dakota, ____________
- Phone Number: ____________
Agent Information
- Full Name: ____________
- Relationship to Principal: ____________
- Address: ____________, ____________, North Dakota, ____________
- Alternative Phone Number: ____________
Alternate Agent Information (Optional)
If the primary Agent is unable, unwilling, or unavailable to perform their duties, an alternate agent can be designated.
- Full Name: ____________
- Relationship to Principal: ____________
- Address: ____________, ____________, North Dakota, ____________
- Phone Number: ____________
Authority Granted to the Agent
This Medical Power of Attorney grants the Agent the authority to make all health-care decisions for the Principal under North Dakota law. This includes, but is not limited to, consenting to or refusing medical treatment, accessing medical records, and making end-of-life decisions. This authority is active when the Principal is determined to be unable to communicate their healthcare decisions.
Limitations on the Agent's Authority
- The Agent cannot make any healthcare decisions contrary to the known desires of the Principal.
- The Agent must always act in the best interest of the Principal.
- Decisions regarding life-sustaining treatment are subject to additional safeguards under North Dakota law.
Effective Date and Signatures
This document becomes effective immediately upon the incapacitation of the Principal and remains in effect until the Principal is again able to make their own health-care decisions or until it is revoked.
Principal Signature: ____________ Date: ____________
Agent Signature: ____________ Date: ____________
Alternate Agent Signature (If applicable): ____________ Date: ____________
Witnesses
North Dakota law requires at least two adult witnesses to the signing of this document. Witnesses cannot be the Agent, a health-care provider, or an employee of a health-care facility where the Principal is receiving care.
1. Witness Signature: ____________ Date: ____________
Print Name: ____________
2. Witness Signature: ____________ Date: ____________
Print Name: ____________