Rhode Island Medical Power of Attorney
This Rhode Island Medical Power of Attorney is created in accordance with the Rhode Island Durable Power of Attorney for Health Care Act (Chapter 23-4.10 of the Rhode Island General Laws). It grants the person you designate (your agent) the authority to make healthcare decisions on your behalf in the event you are unable to do so.
Principal’s Information:
- Full Name: _______________________________
- Date of Birth: ___________________________
- Address: ________________________________
Agent’s Information:
- Full Name: _______________________________
- Relationship to Principal: ________________________
- Primary Phone Number: ___________________________
- Alternate Phone Number: _________________________
- Address: ________________________________
Alternate Agent’s Information (Optional):
- Full Name: _______________________________
- Relationship to Principal: ________________________
- Primary Phone Number: ___________________________
- Alternate Phone Number: _________________________
- Address: ________________________________
In the event that the above-named agent is unable, unwilling, or ineligible to act as my health care representative, the alternate agent shall serve with the same authority.
Special Instructions: (Optional)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Use this space to include any specific wishes, limitations, or additional powers you want your agent to have in making health care decisions for you.
Duration of Authority:
This Medical Power of Attorney becomes effective upon my incapacity to make health care decisions as determined by my attending physician. It remains effective indefinitely unless I revoke it or specify an expiration date below:
Expiration Date (Optional): _____________________
Signature and Acknowledgment:
This document must be signed by the principal in the presence of two (2) witnesses, neither of whom is the agent or alternate agent. The witnesses affirm that the principal appears to understand the nature of the document and is free from duress or undue influence at the time of signing.
Principal’s Signature: _______________________________ Date: ________________
Witness 1 Signature: ________________________________ Date: ________________
Witness 2 Signature: ________________________________ Date: ________________
State of Rhode Island
County of _________________________
This document was acknowledged before me on (date) __________________ by (name of principal) ____________________.
Notary Public: _____________________________________
My commission expires: _____________________________