Hawaii Medical Power of Attorney
This Hawaii Medical Power of Attorney is a crucial document that empowers another individual to make health care decisions on your behalf should you become incapacitated or unable to make those decisions yourself. It's constructed under the guidelines provided in the Uniform Health-Care Decisions Act (Chapter 327E) of Hawaii Revised Statutes. Carefully consider the choice of your agent, who will have the authority to discuss with your healthcare providers and make decisions about your health care as if they were you.
To complete this document, please fill in the required information where the blanks are indicated and discuss your specific wishes regarding health care with your chosen agent.
1. Principal Information
Full Name of Principal: ____________________________
Address: ____________________________
City, State, Zip: ____________________________
Date of Birth: ____________________________
2. Agent Information
Full Name of Agent: ____________________________
Address: ____________________________
City, State, Zip: ____________________________
Telephone Number: ____________________________
Alternate Telephone Number: ____________________________
3. Powers Granted
The above-named Principal does hereby appoint the above-named Agent with the following powers:
- To consult with healthcare providers and access medical records.
- To make healthcare decisions on the Principal’s behalf, including treatment, surgical, and end-of-life decisions.
- To decide on the withdrawal or withholding of life-sustaining treatment if the Principal is in a terminal condition or in a permanent unconscious state, subject to any instructions provided in this document or otherwise communicated by the Principal.
4. Special Instructions
If there are any specific limitations to the powers granted to the Agent or additional instructions regarding healthcare preferences, list them here: ____________________________
5. Duration
This Medical Power of Attorney shall become effective on the date it is signed and executed and shall remain in effect indefinitely unless a specific expiration date is listed here: ____________________________
6. Signature
By signing below, the Principal acknowledges the voluntary creation of this Medical Power of Attorney and affirms the understanding of its content and implications.
Principal's Signature: ____________________________
Date: ____________________________
Agent's Signature: ____________________________
Date: ____________________________
7. Witness Statement
This Medical Power of Attorney must be signed in the presence of two competent adult witnesses, who must not be the appointed Agent or related to the Principal by blood, marriage, or adoption. The witnesses affirm that the Principal appears to understand the nature of the document and is free from undue influence at the time of signing.
Witness 1 Signature: ____________________________
Date: ____________________________
Printed Name: ____________________________
Witness 2 Signature: ____________________________
Date: ____________________________
Printed Name: ____________________________
Additional Notes
It is recommended that you discuss your medical power of attorney with your family, your primary physician, and your agent. Provide each with a copy of the signed document. This document should be reviewed periodically and updated as necessary.