When does a person become a Medical Power of Attorney (MPOA), aka Healthcare Advocate for another person? It is when a person is alive but unable or unwilling to handle their medical decisions. This obligation terminates once a person designates another person or can make medical decisions or a person dies. Here is a checklist of what you need for this role.
Medical Power of Attorney Checklist – What do you need?
- Do you have a completed Medical Power of Attorney document that is signed and dated?
- Have you discussed medical treatment and goals with a person?
- Do you understand what the person’s medical wishes are?
- Does the person have a full resuscitate, partial resuscitate or do not resuscitate order?
- Do family and friends understand the person’s wishes?
- Does the person want family and friends to know their wishes?
- If a person authorizes, will you discuss medical decisions with appropriate family and friends?
- Estate Planning Attorney’s name and contact information:
Person’s Information
- Legal Name:
- Social Security Number (SSN):
- Date of Birth:
Person’s Health Insurance
Health Insurance (primary and excess policy(s) if applicable)
- Carrier & contact info
- Policy number
Dental Insurance
- Carrier & contact info
- Policy number
Eye Insurance
- Carrier & contact info
- Policy number
Primary Care Physician (PCP) Name:
- PCP Address:
- PCP Phone Number:
Specialty Doctor(s) / Chiropractor / Acupuncturist / Other Medical Professional Name:
- Doctor’s Address:
- Doctor’s Phone Number:
Dentist Name:
- Dentist Address:
- Dentist Phone Number:
Optometrist Name:
- Optometrist Address:
- Optometrist Phone Number:
Ophthalmologist Name:
- Ophthalmologist address:
- Ophthalmologist Phone Number:
Medical Power of Attorney Checklist – Additional Information to Know
- Current medical conditions (i.e., high blood pressure, etc.) – list all:
- Past medical conditions / medical history (i.e., cancer, heart condition, etc.):
- Current medications and vitamins (name of medicine or vitamin, dosage, and instructions):
- Allergies to medications and non-medications:
