Can this document be signed electronically?

Yes. Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided the signature demonstrates intent, consent, attribution, and retention. Confirm state exceptions for testamentary documents and other excluded categories.

Are witnesses or a notary required?

It depends on state law. Some states require witnesses, some require notarization, and others accept either. Florida requires two witnesses for durable POAs; always verify the execution rules in the principal's state.

How do I revoke or cancel the document?

A principal can revoke a Durable Power of Attorney for Health Care by executing a written revocation, destroying the original, or creating a new document. Notify the agent and healthcare providers promptly in writing.

What happens if the document has minor mistakes?

Minor errors (typos) may be corrected with an amendment or affidavit; however, missing signatures, incorrect witness counts, or lack of notary where required can render it invalid and may trigger guardianship proceedings.

Can the agent access medical records?

Yes if the document grants records access and the principal signs any required HIPAA authorization. Providers may request a copy of the signed POA and a valid HIPAA release.

Should I store digital copies and originals?

Yes. Keep the original signed document accessible and store encrypted electronic copies. Ensure that authorized agents and providers have certified copies or clear access instructions.

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Durable Power of Attorney for Health Care

Durable Power of Attorney for Health Care

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DURABLE POWER OF ATTORNEY FOR HEALTH CARE

WARNING TO PERSON EXECUTING THIS DOCUMENT

THIS IS AN IMPORTANT LEGAL DOCUMENT WHICH IS AUTHORIZED BY THE KEENE HEALTH CARE AGENT ACT. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR AGENT (THE ATTORNEY-IN-FACT) THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU. YOUR AGENT MUST ACT CONSISTENTLY WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN. EXCEPT AS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THIS DOCUMENT GIVES YOUR AGENT THE POWER TO CONSENT TO YOUR DOCTOR NOT GIVING TREATMENT OR STOPPING TREATMENT NECESSARY TO KEEP YOU ALIVE. NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF SO LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION. IN ADDITION, NO TREATMENT MAY BE GIVEN TO YOU OVER YOUR OBJECTION AT THE TIME, AND HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY NOT BE STOPPED OR WITHHELD IF YOU OBJECT AT THE TIME.

THIS DOCUMENT GIVES YOUR AGENT AUTHORITY TO CONSENT, TO REFUSE TO CONSENT, OR TO WITHDRAW CONSENT TO ANY CARE, TREATMENT, SERVICE, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL CONDITION. THIS POWER IS SUBJECT TO ANY STATEMENT OF YOUR DESIRES AND ANY LIMITATIONS THAT YOU INCLUDE IN THIS DOCUMENT. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT THAT YOU DO NOT DESIRE. IN ADDITION, A COURT CAN TAKE AWAY THE POWER OF YOUR AGENT TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOUR AGENT (1) AUTHORIZES ANYTHING THAT IS ILLEGAL, (2) ACTS CONTRARY TO YOUR KNOWN DESIRES, OR (3) WHERE YOUR DESIRES ARE NOT KNOWN, DOES ANYTHING THAT IS CLEARLY CONTRARY TO YOUR BEST INTERESTS.

THE POWERS GIVEN BY THIS DOCUMENT WILL EXIST FOR AN INDEFINITE PERIOD OF TIME UNLESS YOU LIMIT THEIR DURATION IN THIS DOCUMENT. YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY OF YOUR AGENT BY NOTIFYING YOUR AGENT OR YOUR TREATING DOCTOR, HOSPITAL, OR OTHER HEALTH CARE PROVIDER ORALLY OR IN WRITING OF THE REVOCATION. YOUR AGENT HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT. UNLESS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THIS DOCUMENT GIVES YOUR AGENT THE POWER AFTER YOU DIE TO (1) AUTHORIZE AN AUTOPSY, (2) DONATE YOUR BODY OR PARTS THEREOF FOR TRANSPLANT OR THERAPEUTIC OR EDUCATIONAL OR SCIENTIFIC PURPOSES, AND (3) DIRECT THE DISPOSITION OF YOUR REMAINS.

THIS DOCUMENT REVOKES ANY PRIOR DURABLE POWER OF ATTORNEY FOR HEALTH CARE.

YOU SHOULD CAREFULLY READ AND FOLLOW THE WITNESSING PROCEDURE DESCRIBED AT THE END OF THIS FORM. THIS DOCUMENT WILL NOT BE VALID UNLESS YOU COMPLY WITH THE WITNESSING PROCEDURE.

IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.

YOUR AGENT MAY NEED THIS DOCUMENT IMMEDIATELY IN CASE OF AN EMERGENCY THAT REQUIRES A DECISION CONCERNING YOUR HEALTH CARE. EITHER KEEP THIS DOCUMENT WHERE IT IS IMMEDIATELY AVAILABLE TO YOUR AGENT AND ALTERNATE AGENTS OR GIVE EACH OF THEM AN EXECUTED COPY OF THIS DOCUMENT. YOU MAY ALSO WANT TO GIVE YOUR DOCTOR AN EXECUTED COPY OF THIS DOCUMENT.

DO NOT USE THIS FORM IF YOU ARE A CONSERVATEE UNDER THE LANTERMAN-PETRIS-SHORT ACT AND YOU WANT TO APPOINT YOUR CONSERVATOR AS YOUR AGENT. YOU CAN DO THAT ONLY IF THE APPOINTMENT DOCUMENT INCLUDES A CERTIFICATE OF YOUR ATTORNEY.

1. DESIGNATION OF HEALTH CARE AGENT.

I, do hereby designate and appoint as my agent to make health care decisions for me as authorized in this document.

For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition.

2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE.

By this document I intend to create a durable power of attorney for health care under Sections 4600 to 4752, inclusive, of the California Probate Code. This power of attorney is authorized by the Keene Health Care Agent Act and shall be construed in accordance with the provisions of Sections 4770 to 4779, inclusive, of the Probate Code. This power of attorney shall not be affected by my subsequent incapacity.

3. GENERAL STATEMENT OF AUTHORITY GRANTED.

Subject to any limitations in this document, I hereby grant to my agent full power and authority to make health care decisions for me to the same extent that I could make those decisions for myself if I had the capacity to do so.

In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, including, but not limited to, my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures.

4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS.

In exercising the authority under this durable power of attorney for health care, my agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated below:

(a) Statement of desires concerning life-prolonging care, treatment, services, and procedures:

(b) Additional statement of desires, special provisions, and limitations:

5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH.

Subject to any limitations in this document, my agent has the power and authority to request, review, and receive information regarding my physical or mental health, execute releases or other documents to obtain this information, and consent to disclosure of this information.

6. SIGNING DOCUMENTS, WAIVERS, AND RELEASES.

Where necessary to implement the health care decisions that my agent is authorized by this document to make, my agent has the power and authority to execute on my behalf all necessary documents, waivers, and releases.

7. AUTOPSY; ANATOMICAL GIFTS; DISPOSITION OF REMAINS.

Subject to any limitations in this document, my agent has the power and authority to authorize an autopsy, make a disposition of a part or parts of my body, and direct the disposition of my remains.

8. DURATION.

This durable power of attorney for health care expires on

Leave blank if you want this power of attorney to exist for an indefinite period of time.

9. DESIGNATION OF ALTERNATE AGENTS.

If the person designated as my agent in paragraph 1 is not available or becomes ineligible to act as my agent, then I designate and appoint the following persons to serve in the order listed below:

A. First Alternate Agent

B. Second Alternate Agent

10. NOMINATION OF CONSERVATOR OF PERSON.

If a conservator of the person is to be appointed for me, I nominate the following individual to serve as conservator of the person:

11. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH.

A. General Grant of Power and Authority. Subject to any limitations in this Directive, my agent has the power and authority to request, review, and receive information, execute releases, consent to disclosure, and consent to the donation of organs for medical purposes.

B. HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my health information. This release authority applies to information governed by HIPAA.

12. PRIOR DESIGNATIONS REVOKED.

I revoke any prior durable power of attorney for health care.

DATE AND SIGNATURE OF PRINCIPAL

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)

Date

City

State

(You sign here)

STATEMENT OF WITNESSES

This document must be witnessed by two qualified adult witnesses. None of the following may be used as a witness: a person you designate as your agent or alternate agent, a health care provider, an employee of a health care provider, an operator or employee of a community care facility, or an operator or employee of a residential care facility for the elderly.

Witness 1 Signature

Residence Address

Print Name

Date

Witness 2 Signature

Residence Address

Print Name

Date

Additional Declaration of Witness (if applicable)

STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN

If you are a patient in a skilled nursing facility, one of the witnesses must be a patient advocate or ombudsman.

Patient Advocate or Ombudsman Signature

What a Durable Power of Attorney for Health Care Is

A Durable Power of Attorney for Health Care is a legal document that designates an agent to make medical and health care decisions on behalf of another person if they become unable to decide for themselves. It typically covers treatment preferences, surrogate decision-making, access to medical records, and the authority to consent to or refuse specific medical interventions. Unlike a general power of attorney, the term "durable" keeps the agent's authority in effect after the principal becomes incapacitated. State statutes and health privacy laws influence form wording and required execution steps.

Why a Durable Power of Attorney for Health Care Matters

A properly executed Durable Power of Attorney for Health Care lets you name a trusted person to make timely medical decisions, reduces the chance of court-appointed guardianship, and clarifies your treatment preferences for providers and family members.

Who Typically Completes This Document

Healthcare providers, attorneys, and patient advocates also work with principals to ensure the document meets state law and clinical requirements.

Elderly individuals planning long-term care and end-of-life preferences.
Adults with chronic or progressive illnesses who want a designated healthcare decision-maker.
Caregivers and family members coordinating medical decisions for an incapacitated relative.

Step-by-Step: Completing the Durable Power of Attorney for Health Care

Complete, sign, and authenticate the document in the correct order to avoid invalidation.

01

Prepare: Gather IDs, agent contact details, and any treatment preferences.
02

Fill: Enter names, dates, scope of authority, and successor agents.
03

Authenticate: Observe witness signatures or notarization per state requirements.
04

Distribute: Provide copies to the agent, providers, and your medical record.

Configuring an Online Completion Workflow

Set up an e-signature workflow that enforces required fields, signer order, and authentication to meet legal and clinical needs.

Field	Configuration
Required Fields	Make name, signature, and date mandatory.
Signer Order	Principal signs first, then witnesses or notary as required.
Authentication	Use email plus SMS code or stronger ID verification.
Audit Trail	Enable full event logging and timestamp capture.

Where to Send and Who Receives Copies

After execution, route the document to clinical and legal stakeholders to ensure access when decisions are needed.

Primary Agent: Provide a signed copy and contact information for immediate use.
Health Care Provider: Deliver a copy to your primary care provider and hospital records.
Medical Records: Upload to the patient portal or include in the electronic health record.
Family/Proxy: Share copies with relevant family members and successor agents.

Digital Signing and Secure Distribution Requirements

Ensure the chosen solution can provide proof of signature events, retain tamper-evident copies, and meet applicable privacy requirements.

Format Support: PDF and PDF/A preservation.
Authentication: Email+SMS, KBA, or government ID verification.
Integrations: EMR and cloud storage connections.

Typical eSignature Provider Pricing and Capabilities for This Document

Comparing baseline pricing and common capabilities can help when selecting an eSignature provider for healthcare forms; signNow is listed first per comparison rules.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no credit card	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	Yes
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Security and Compliance Elements to Verify

In Transit: TLS 1.2/1.3

At Rest: AES-256 encryption

Certifications: SOC 2 Type II

Healthcare: HIPAA BAA required

FDA Records: 21 CFR Part 11 support

Legal Framework: ESIGN and UETA compliance

Primary Risks if the Document Is Improperly Prepared

Invalid Execution: Document may be unenforceable

Delayed Care: Providers may withhold treatment

Guardianship: Court appointment may be required

Privacy Breach: Unauthorized records access

Agent Disputes: Family conflicts over decisions

Scope Gaps: Agent lacks authority for needed actions

Common Preparation Mistakes to Avoid

Using informal language or vague authority that courts or providers will not interpret consistently across care settings.
Failing to name successor agents, which can leave no clear decision-maker if the primary agent cannot serve.
Omitting witness or notary steps required by state law, creating risk the document will not be accepted by hospitals.
Not providing signed copies to providers and pharmacies, which prevents prompt access to authority in emergencies.

Timing Considerations and Execution Priorities

There are no IRS-style filing deadlines for health care POAs, but timing and immediate distribution are important for usability.

Provision Date:

Set an effective date and record it clearly

Execution Timing:

Sign while mentally competent and before planned procedures

Provider Delivery:

Give copies to providers immediately after signing

Notary/Witness:

Complete authentication steps at signing to ensure acceptance

Periodic Review:

Review and update every few years or after major life events

Key Milestones from Draft to Use

Track milestones from drafting through distribution to ensure the Durable Power of Attorney for Health Care is available when needed.

01

Draft Document

Decide agent, successors, scope, and preferences.

02

Execution

Sign with required witnesses or notary present.

03

Record & Share

Provide copies to providers and upload to records.

04

Review Cycle

Revisit the document after major health or life changes.

Practical Tips for Accurate and Efficient Completion

Adopt clear practices to reduce ambiguity, speed provider acceptance, and minimize later disputes.

Use Clear and Specific Authority Language

State specific decision areas (surgery, life-sustaining treatment, medications) and any limits to agent authority to avoid later disputes or provider uncertainty. Precision reduces interpretation risk.

Confirm State Requirements Before Signing

Check whether your state requires witnesses, notarization, or specific statutory text. Compliance with state rules helps ensure the document will be accepted by hospitals and clinics.

Distribute Immediately to Providers

Provide signed copies to your primary care physician, local hospital, and any specialist. Upload an electronic copy to patient portals and give a copy to the agent to carry.

Retain an Unaltered Original

Keep the original signed paper or a tamper-evident PDF for the file; many institutions will request a certified copy or notarized original if disputes arise.

Real-World Examples of Use

These brief examples illustrate how organizations and individuals have used electronic execution and storage for health care POAs.

Optica Ventures (Operational Use)

Optica adopted electronic execution to reduce turnaround and improve access to completed forms.

Their team used templated forms and secure routing for signatures.
The approach reduced time to availability and ensured agents had immediate access to signed copies when clinical decisions were needed.

Fertility Centers of Illinois (Healthcare)

The clinic implemented remote signing and secure storage to streamline patient intake.

They integrated signed forms into the EHR.
This integration ensured that authorized agents could be recognized promptly and that staff had consistent documentation for treatment decisions.

Frequently Asked Questions

Answers to common questions about legality, electronic signing, witnesses, notarization, and revocation for Durable Powers of Attorney for Health Care.

Need help? Contact support

Can this document be signed electronically?
Yes. Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided the signature demonstrates intent, consent, attribution, and retention. Confirm state exceptions for testamentary documents and other excluded categories.
Are witnesses or a notary required?
It depends on state law. Some states require witnesses, some require notarization, and others accept either. Florida requires two witnesses for durable POAs; always verify the execution rules in the principal's state.
How do I revoke or cancel the document?
A principal can revoke a Durable Power of Attorney for Health Care by executing a written revocation, destroying the original, or creating a new document. Notify the agent and healthcare providers promptly in writing.
What happens if the document has minor mistakes?
Minor errors (typos) may be corrected with an amendment or affidavit; however, missing signatures, incorrect witness counts, or lack of notary where required can render it invalid and may trigger guardianship proceedings.
Can the agent access medical records?
Yes if the document grants records access and the principal signs any required HIPAA authorization. Providers may request a copy of the signed POA and a valid HIPAA release.
Should I store digital copies and originals?
Yes. Keep the original signed document accessible and store encrypted electronic copies. Ensure that authorized agents and providers have certified copies or clear access instructions.

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