Michigan Patient Advocate Designation Form (Medical POA)

In the U.S., those who like thinking ahead try to protect themselves and people around them by completing a medical power of attorney form. It is a commonly used legal document. The name of the paper may vary from state to state. In the state of Michigan, the form is referred to as Patient Advocate Designation (also known as Form DCH-3916). Although the structure and terms may be different in each state, the forms have the same function regardless of the state. In Michigan, the MPOA form is an independent document that can be attached to other forms (for example, a Living Will form).

Regardless of age, any person can get into a situation that will prevent them from making decisions regarding health care themselves. Thus, it is a good idea to identify who will make them before such situations happen. The MPOA form allows an individual (the principal) to select a person (the agent) who will act and communicate on the individual’s behalf when dealing with serious healthcare decisions in the best interests of the individual themselves and in accordance with their beliefs. It may come in handy when the principal loses the capacity to give instructions and communicate their wishes due to some severe disease or getting into a permanent unconscious or vegetative state.

Michigan power of attorney forms – take a look at several other powers of attorney common in Michigan.

michigan medical poa

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Michigan Laws and Requirements

Do not forget to get acquainted with all the laws and requirements when you decide to complete the form and choose a representative to delegate powers to. You will find all the necessary information below.

As stated in section 700.5506 of Michigan Compiled Laws, you cannot create and sign the document unless you are an adult with a decision-making capacity (you should be at least 18 years old). The form comes into effect when a person’s physician determines that the principal is no longer competent to communicate decisions. If an agent has the right to make decisions regarding organ donation, the document will remain in effect even when the principal passes away.

According to the section mentioned above, apart from the principal’s signature, it is mandatory that the signatures of two witnesses must be provided. They acknowledge that the document is legal, and the declarant is of sound mind and capable of understanding the document’s essence. Keep in mind that your family members, doctor, or any employee who provides you with healthcare cannot act as witnesses. In the state of Michigan, there are no statutes demanding that you should notarize the form to make it completely valid.

Make sure that you have given a copy to each party engaged: your doctor and your agent. Do not forget to print a copy for yourself. All copies of the document must be signed in the required lines.

Michigan Medical Power of Attorney Form Details

Document Name Michigan Medical Power of Attorney Form
State Form Name Michigan Patient Advocate Designation
State Laws Michigan Compiled Laws, Sections 700.5501 to 700.5520
Signing Requirements Two Witnesses
Who Can’t Be the Agent? Not specified
Who Can’t Be the Witness? Section 700.5506(4)
Avg. Time to Fill Out 8 minutes
# of Fillable Fields 21
Available Formats Adobe PDF

Filling Out the Form

In the state of Michigan, the document consists of seven pages. If you read the detailed instruction below, the process of completing the form will not be too time-consuming.

  • Download the MPOA Template

Before you begin to fill out the form, download it. To make the downloading process quicker, use our form building software. You can use any technological device to input the necessary information.

  • Tick the Box

In Michigan, the form starts with basic information about the form, requirements you are to satisfy, and your responsibilities and rights. If you want to appoint an agent (in the state of Michigan, they are referred to as patient advocates), choose the box with the statement claiming that you agree to complete the form.

  • Provide the Principal’s Personal Details

You, as the principle, should specify your identity. In the blank lines below the document’s title, insert your full name, address, the date on which you were born, and four digits your Social Security Number ends with.
Principal's personal details indication section of a medical power of attorney document for Michigan

  • Designate Your Patient Advocate

The next blank lines are meant for inputting the personal details belonging to the chosen patient advocate. Start with your own name and then proceed to insert the representative’s name, address, and contacts (such as telephone number). Make sure that your agent meets all the state requirements.
Patient advocate designation section of a Michigan medical power of attorney template

  • Appoint an Alternate Patient Advocate

In the state of Michigan, you are allowed to choose a backup agent who will have the same responsibilities as the agent you designated in the first place. These are certain situations that can prevent your primary representative from acting and communicating on your behalf. Fill in the personal information about the new agent (name, address, phone number).
Alternate patient advocate designation section of a Michigan medical power of attorney document

  • Check the Box (If Needed)

If you are a follower of a certain religion that prohibits being examined by a doctor or any other medical professional, choose the box and indicate who has verified your inability to communicate mental health decisions.
Part for checking the box of Michigan mpoa document

  • Specify Restrictions and Limitations (If Needed)

After you have read the information about the powers you delegate to your patient advocate, proceed to the next section, which allows you to either limit or to expand the scope of your agent’s responsibilities. If you do not want to write any additional wishes, choose the first box provided in the section.
Restrictions and limitations specification section of Michigan medical poa form

  • Indicate What Decisions Your Patient Advocate Can Make 

In the next section, you are provided three separate boxes in which you need to specify what kind of decisions your agent is responsible for. An agent can gain powers concerning:

  • Treatment that helps to sustain life;
  • Organ donation;
  • Treatment regarding mental health care.

If you delegate any of the powers provided, sign at the bottom of the box. Choose one or several options in the box if necessary. In the box regarding mental health care decisions, add some more wishes if you want. Do not forget to insert the date in each box you sign.
Information about patient advocate's decisions part of a mpoa for Michigan

  • Provide Your Signature

Check all the information you have provided twice and proceed to this section. You are to sign the document and insert your personal information. It is also necessary to input the date on which the document is executed.
Signature part of Michigan mpoa document

  • Ask Two Witnesses to Sign

As has been stated above, the law demands that you should have two witnesses to sign the document to make it valid. Ask them to insert the date, their names, and addresses. Remember that there are certain limitations regarding the choice of a witness.
Witnesses signing part of Michigan mpoa template

  • Let the Patient Advocate(s) to Sign the Paper

The last two pages of the document are dedicated to the agent(s) responsibilities and their acceptance. Ask them to insert their names, your name, and the date. After they have provided the above-mentioned details, they are to sign the paper.
Patient advocate signing part of Michigan medical power of attorney

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Published: Dec 7, 2020