North Carolina Medical Power of Attorney (POA) Form

According to the law of the USA, all individuals 18 years of age may initiate creation of a Medical Power of Attorney. This document is also known as “Advance Directive,” and it serves as legal evidence that a person (the principal) has designated an agent to act on the principal’s behalf if the latter experiences incapacitation and is not able to make decisions upon health care treatment.

The medical power of attorney form in each state is regulated by specific local laws. Thus it is recommended to study all the necessary MPOA-related information prior to initiating its completion.

In North Carolina, the MPOA has to be witnessed by two adults and notarized.

North Carolina power of attorney forms – download more power of attorney forms for North Carolina together with instructions.

North Carolina Signing Requirements and Laws

  • 32A-16 describes the following definitions you will see in the document:
  • Health Care Agent: an adult, appointed by the principal to perform on his or her behalf when it is required to provide the physician(s) with medical decisions;
  • Life-Prolonging Measures: mechanical ventilation, artificial nutrition, hydration, and similar types of treatment meant to postpone the life of a patient;
  • Principal: a person who has reached the age of 18, the sound of mind, and willing to provide a written directive, meant to be executed by his or her attending physician at the moment the person is unable to speak for himself (herself).
  • Qualified Witness: an adult (not related to the principal) in whose presence the document is being submitted.

Ensure you are appointing an agent the trustworthy person you are familiar with, and believe him or her to act in your interest once you might experience incapacitation, disability, coma, or vegetative state. The document will provide your attorney with broad powers, including but not limited by withholding or withdrawal life-prolonging procedures.

You may wish to initiate revocation of the MPOA at any time if you are sound of mind and able to sign a new paper or tell your attending physician about your decision. If you have not revoked the paper, it will be considered effective until the moment of death.

Filling Out the Form

To successfully complete the paper, follow the set of step-by-step instructions below:

  • Get the Template

Once you have decided to create the Medical Power of Attorney, download the form from any reliable source page, or use our form building software.

  • Designate the Agent

The principal is supposed to provide his or her full name, being sound of mind and willing to grant the medical powers to a chosen attorney-in-fact. Then enter the name, address, home, work, and cellular phones of the agent. If you wish, you may designate two alternative attorneys meant to perform their duties in case the original agent is unable or unwilling to do so.
Agent designation part of north carolina medical power of attorney

  • Provide Physician(s) Info

The attorney is supposed to become effective the moment one or two physicians you list in this section determine a lack of capacity to make decisions related to your health care. If the physician(s) are not found available, the determination should be stated by an attending physician.
Physicians information section of a medical power of attorney form for North Carolina

  • Indicate Special Provisions or Limitations

The next section describes the set of powers you grant your agent, including artificial nutrition or hydration, limitations concerning health care decisions, mental health treatment, autopsy, and disposition of remains. If you wish to limit the scope of powers, you may enter specific preferences in the blocks and initial the corresponding boxes. If you do not submit special limitations and leave the boxes not initialed, your health care agent will be authorized to make any decisions you could make to obtain or terminate health care treatment.
Special provisions or limitations indications of a North Carolina mpoa template

  • Express Your Wishes upon Organ Donation

If you intend to donate the body or body parts, enter the limitations you consider appropriate and initial the corresponding boxes.
Part for information about organ donation section of North Carolina mpoa form

  • Put the Principal’s Signature

After you have studied all the information provided in the MPOA and filled out additional instructions (limitations), insert the date and affix the signature.
Principal's signature part of North Carolina medical power of attorney template

  • Witness the Paper

Two adult witnesses, being first duly sworn, have to sign their full names, stating that the principal has completed the form sound of mind and under no influence. Input the date, county, and state where the MPOA is being created.
Witness part of mpoa for North Carolina

  • Notarize the Document 

A licensed notary should type or print the names of both witnesses and the principal, insert the date, provide credentials, commission expiration date, and the county.
Notarization section of a medical poa for North Carolina

Other North Carolina Forms

Use our document maker to personalize any template available on FormsPal to your requirements. Here’s a range of other printable North Carolina forms we offer.

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Published: Nov 19, 2020