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Legal Medical Power of Attorney Document for Vermont

The Vermont Medical Power of Attorney form is a legal document that allows you to designate someone to make healthcare decisions on your behalf if you become unable to do so. This essential tool ensures your medical preferences are honored, providing peace of mind for you and your loved ones. Take the important step of filling out this form by clicking the button below.

Open Medical Power of Attorney Editor

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The Vermont Medical Power of Attorney form serves as a crucial legal document that empowers individuals to designate a trusted person to make medical decisions on their behalf in the event they become unable to communicate their wishes. This form is particularly important for ensuring that healthcare choices align with personal values and preferences, especially during critical moments when immediate decisions are necessary. By appointing an agent, the individual can ensure that their medical treatment aligns with their desires, whether it involves life-sustaining measures or end-of-life care. The form outlines the responsibilities of the appointed agent and can include specific instructions regarding medical treatments, thereby providing clarity and guidance to healthcare providers. Additionally, it is essential for individuals to understand that this document can be revoked or modified at any time, as long as they are still capable of making decisions. In Vermont, the Medical Power of Attorney form must be signed and witnessed to be valid, ensuring that the individual's choices are respected and upheld in medical settings.

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Vermont Medical Power of Attorney

This Medical Power of Attorney is a legal document that grants an individual (the "Principal") the power to appoint an agent (the "Attorney-in-fact" or "Healthcare Agent") to make healthcare decisions on the Principal's behalf if the Principal is unable to communicate or make informed decisions due to incapacity or illness. This document is designed in accordance with the laws of the State of Vermont, specifically under the “Vermont Patient Choice at End of Life Act” and other relevant state laws. It is crucial that the Principal, the Healthcare Agent, and any involved parties fully understand their rights and responsibilities as outlined in this document.

Please complete the following information accurately:

Principal's Information:

Full Name: ___________________________________________________
Date of Birth: _________________________________________________
Address: ______________________________________________________
City: ________________________ State: VT Zip Code: _______________
Primary Telephone: _____________________________________________

Healthcare Agent's Information:

Full Name: ___________________________________________________
Relationship to Principal: _____________________________________
Address: ______________________________________________________
City: ________________________ State: ____ Zip Code: ______________
Primary Telephone: _____________________________________________
Alternate Telephone: ___________________________________________

By this document, the Principal intends to create a Medical Power of Attorney and hereby nominates the above-named Agent to make healthcare decisions on his/her behalf as authorized in this document. This authority includes, but is not limited to, the power to consent, refuse, or withdraw consent to all medical, surgical, hospital, and related healthcare services and procedures that a healthcare provider may deem necessary or advisable, including the administration of pain-relieving measures and the power to apply for medical benefits on the Principal's behalf.

This Medical Power of Attorney becomes effective upon the Principal's incapacity to make healthcare decisions, as certified in writing by the attending physician. The authority of the Healthcare Agent under this document shall continue until the Principal's death unless the Principal revokes the power.

The Principal has the right to revoke this Medical Power of Attorney at any time by communicating the revocation in writing to both the Healthcare Agent and to any treating healthcare provider.

Signature of Principal: ________________________________________

Date: ___________________

Signature of Healthcare Agent: ___________________________________

Date: ___________________

This document must be signed in the presence of two adult witnesses, who are not related to the Principal by blood, marriage, or adoption, and who are not entitled to any portion of the estate of the Principal under any will of the Principal or codicil thereto or by operation of any law now existing or hereafter enacted. The witnesses must not be the attending physician, an employee of the attending physician or healthcare facility, or have any claim against the Principal's estate.

Witness 1:

Full Name: ___________________________________________________
Signature: ____________________________________________________
Date: ________________________________________________________

Witness 2:

Full Name: ___________________________________________________
Signature: ____________________________________________________
Date: ________________________________________________________

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File Characteristics

Fact Name	Description
Definition	A Vermont Medical Power of Attorney allows an individual to designate someone to make healthcare decisions on their behalf if they become unable to do so.
Governing Law	This form is governed by Vermont Statutes Title 18, Chapter 231, which outlines the laws regarding advance directives and medical powers of attorney.
Eligibility	Any adult who is at least 18 years old and of sound mind can create a Medical Power of Attorney in Vermont.
Agent Requirements	The person chosen as an agent must be at least 18 years old and cannot be the individual's healthcare provider or an employee of the healthcare provider.
Revocation	The principal can revoke the Medical Power of Attorney at any time, as long as they are still competent to make decisions.
Witnesses	The document must be signed in the presence of two witnesses or a notary public to be considered valid.

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