OMR: Proxy Form

A medical or healthcare proxy or power of attorney is a legal document. Laws governing such documents vary from state to state.

The sample form which OMR provides may be applicable in your state. It is suggested that you check with your healthcare provider or attorney to determine your state's requirements. Once you have completed your proxy form, had it signed and witnessed, register your information online with OMR. OMR also permits subscribers to store a scanned copy of their executed proxy, which can be printed by a hospital.

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MEDICAL/HEALTHCARE PROXY

Name of Principal	____________________________________________
Address of Principal	____________________________________________
Home Phone of Principal	____________________________________________
Other Phone of Principal	____________________________________________
Email of Principal	____________________________________________
Date of Birth of Principal	____________________________________________

I appoint as my HEALTHCARE AGENT

Name of Agent	____________________________________________
Address of Agent	____________________________________________
Home Phone of Agent	____________________________________________
Other Phone of Agent	____________________________________________
Email of Agent	____________________________________________

I appoint as my ALTERNATE HEALTHCARE AGENT

Name of Alternate Agent	____________________________________________
Address of Alternate Agent	____________________________________________
Home Phone of Alternate Agent	____________________________________________
Other Phone of Alternate Agent	____________________________________________
Email of Alternate Agent	____________________________________________

My Healthcare Agent shall have authority to make all healthcare decisions for me including decisions about life sustaining treatment, if I am unable to do so. My Healthcare Agent's authority becomes effective if my attending physician states in writing that I am unable to make decisions or communicate healthcare decisions for myself. My Healthcare Agent will then have authority to make such decisions with the following limitations, if any.
Optional: attach any special instructions, limits to Agent's authority and/or exclusions of or desire for certain treatments.

I direct my Healthcare Agent to make healthcare decisions based on my Healthcare Agent's assessment of my wishes. If my wishes are unknown, my Healthcare Agent is to make those decisions based on assessment of my best interests. Photocopies or scanned images of this document shall have the same force and effect as the original, and may be given to other healthcare providers.

I am an organ donor I have prepared special instructions I have a Do Not Resuscitate (DNR) Order

SIGNED:__________________________________(Principal) _______________(Date Signed)

This statement must be signed in the presence of two Witnesses who may not be the Healthcare Agent or Alternate Healthcare Agent listed above: nor a minor, heir, relative, creditor, conservator, person responsible for care cost, healthcare provider or facility.

I, the undersigned, have witnessed the signing of this healthcare proxy by the Principal, and state that the Principal is at least 18 years of age, of sound mind, and under no constraint or undue influence.

__________________________________ (Witness - Signature)		__________________________________ (Witness - Signature)
__________________________________ (Print Name)		__________________________________ (Print Name)
__________________________________ (Print Street Address)		__________________________________ (Print Street Address)
__________________________________ (Print City, State ZIP)		__________________________________ (Print City, State ZIP)