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):
