Rhode Island Medical Power of Attorney
This Rhode Island Medical Power of Attorney is a legal document that allows an individual (the "Principal") to designate another person (the "Agent") to make health care decisions on their behalf if they are unable to do so. This document is governed by the Rhode Island Health Care Power of Attorney Act.
Principal Information
Full Name: ____________________________
Address: ____________________________
City: ____________________________
State: Rhode Island
Zip Code: ____________________________
Date of Birth: ____________________________
Telephone Number: ____________________________
Agent Information
Full Name of Agent: ____________________________
Address: ____________________________
City: ____________________________
State: ____________________________
Zip Code: ____________________________
Telephone Number: ____________________________
Alternate Agent Information (Optional)
Full Name of Alternate Agent: ____________________________
Address: ____________________________
City: ____________________________
State: ____________________________
Zip Code: ____________________________
Telephone Number: ____________________________
General Powers Granted
By signing this document, the Principal grants the Agent full power and authority to make health care decisions on their behalf. This includes, but is not limited to:
- Choosing or changing medical care and treatment
- Accessing medical records
- Making decisions about life-sustaining treatment
- Admitting or discharging the Principal from any hospital, nursing home, or other medical care facility
Special Instructions
The Principal may specify any limitations on the Agent's powers or any special instructions here:
________________________________________________________________
________________________________________________________________
Signatures
This document must be signed by the Principal, the designated Agent, and an adult witness or a notary public to be legally binding.
Principal's Signature: ____________________________ Date: ____________________________
Agent's Signature: ____________________________ Date: ____________________________
Alternate Agent's Signature (if applicable): ____________________________ Date: ____________________________
Affirmation by Witness or Notary:
________________________________________________________________
Effective Date and Revocation
This document becomes effective immediately upon the incapacity of the Principal, as determined by a physician. The Principal may revoke this document at any time by notifying the Agent or Alternate Agent in writing.