South Carolina Medical Power of Attorney
This Medical Power of Attorney is an important legal document. It grants authority to a chosen individual to make medical decisions on your behalf should you become unable to do so yourself. This document is specifically tailored to comply with the South Carolina Adult Health Care Consent Act.
Please fill in the following sections with the required information to ensure this document accurately reflects your wishes.
Part 1: Designation of Health Care Agent
I, ____________ [Your Full Name], residing at ____________ [Your Address], hereby appoint ____________ [Agent's Full Name], residing at ____________ [Agent's Address], as my Health Care Agent to make any and all health care decisions for me, except to the extent that I state otherwise. This appointment shall take effect in the event that I become unable to make my own health care decisions.
Part 2: Powers of Health Care Agent
My Health Care Agent is authorized to:
- Consult with my physicians and other health care providers regarding my medical care.
- Access my medical records.
- Make decisions regarding my medical care, including, but not limited to, consenting to or refusing any medical treatment on my behalf.
- Authorize my admission to or discharge from any hospital, nursing home, or other medical care facility.
- Make decisions regarding palliative care and pain management.
- Authorize the donation of my organs or body for transplantation or research, if I have not indicated a decision.
Part 3: Special Instructions
In the space below, you may give special instructions to your Health Care Agent, including any specific limitations you place on their powers or preferences about your medical care:
______________________________________________________________________________
______________________________________________________________________________
Part 4: Duration
This Medical Power of Attorney will remain in effect unless I revoke it or it is terminated by my death, except as to my body's posthumous organ donation wishes, which shall survive my death to the extent necessary to effectuate such donation.
Part 5: Signature
By signing below, I validate that this Medical Power of Attorney reflects my wishes and that I am executing it voluntarily:
________________________________ [Your Signature]
________________________________ [Date]
Part 6: Witness Statement
We, the undersigned, declare under penalty of perjury that the principal appears to be of sound mind and under no duress, fraud, or undue influence. We are not health care providers nor the designated agent or related to the agent by blood, adoption, or marriage:
- Witness 1: ____________ [Print Name] __________________ [Signature] ____________ [Date]
- Witness 2: ____________ [Print Name] __________________ [Signature] ____________ [Date]
Part 7: Acceptance by Health Care Agent
I, ____________ [Agent's Full Name], accept this designation as Health Care Agent and acknowledge that when I act under this authority, I must act in accordance with the principal's desires as stated in this document or otherwise made known to me.
________________________________ [Agent's Signature]
________________________________ [Date]