Medical Power of Attorney Form for Ohio

STATE OF OHIO HEALTH CARE POWER OF ATTORNEY

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1. STATUTORY & LEGAL COMPLIANCE NOTICE

NOTICE TO PERSON EXECUTING THIS DOCUMENT: This is an important legal document. Before executing this document, you should know these important facts:

This document gives the person you designate (the attorney-in-fact) the power to make MOST health care decisions for you if you lose the capacity to make informed health care decisions for yourself. This power is effective only when your attending physician determines that you have lost the capacity to make informed health care decisions for yourself and, notwithstanding this document, as long as you have the capacity to make informed health care decisions for yourself, you retain the right to make all medical and other health care decisions for yourself.

You may include in this document any specific limitations or restrictions on the authority of your attorney-in-fact. This document does not give your attorney-in-fact the power to consent to abortion or to the withdrawal of life-sustaining treatment in certain specific circumstances.

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2. PARTIES & RECITALS

2.1 THE PRINCIPAL: This Health Care Power of Attorney is executed by [Principal Full Legal Name], residing at [Principal Address] (hereinafter referred to as the "Principal").

2.2 THE ATTORNEY-IN-FACT: The Principal hereby designates and appoints [Agent Full Legal Name], residing at [Agent Address], as the Principal's true and lawful Attorney-in-Fact (the "Agent") to make health care decisions for the Principal as authorized in this instrument.

2.3 SUCCESSOR AGENTS: In the event the Agent is unable, unwilling, or unavailable to serve, the Principal hereby appoints the following individuals in the order of priority listed:

1. [First Successor Full Legal Name], residing at [Address]
2. [Second Successor Full Legal Name], residing at [Address]

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3. EXHAUSTIVE OPERATIVE CLAUSES & LEGAL TERMS

3.1 Scope of Authority & Triggering Event

The authority granted under this instrument shall remain dormant until such time as the Principal’s attending physician determines, in accordance with Ohio Revised Code § 1337.13, that the Principal has lost the capacity to make informed health care decisions. Upon such determination, the Agent shall have full power and authority to provide informed consent, refuse consent, or withdraw consent to any health care, including but not limited to medical, surgical, dental, or psychological care, treatment, service, or procedures.

3.2 Specific Powers and HIPAA Authorization

The Agent is hereby authorized to: (a) Access, review, and receive any information, verbal or written, regarding the Principal's physical or mental health, including medical and hospital records. (b) Execute on the Principal's behalf any releases or other documents that may be required in order to obtain this information. (c) This section serves as a formal HIPAA Authorization pursuant to the Health Insurance Portability and Accountability Act of 1996 and 45 C.F.R. § 164.502(g)(1). The Agent shall be treated as the Principal would be with respect to rights regarding the use and disclosure of the Principal's individually identifiable health information or other medical records.

3.3 Compensation, Invoicing, and Reimbursement

The Agent shall serve without direct compensation for services rendered. However, the Agent is entitled to reimbursement for all reasonable and necessary expenses incurred in the exercise of the powers granted herein, including but not limited to travel, lodging, and professional consultation fees. Such expenses shall be paid from the Principal's assets. If the Agent is a professional fiduciary, their standard fee schedule as of [Effective Date] shall apply, with invoices submitted monthly to the Principal's estate or legal representative. Late payments shall accrue interest at a rate of 1.5% per month or the maximum rate permitted by Ohio law.

3.4 Term, Termination, and Revocation

This instrument shall remain in effect until the death of the Principal or until revoked. The Principal may revoke this Health Care Power of Attorney at any time and in any manner, provided the Principal has the capacity to do so. Revocation is effective upon communication to the Agent or the Principal's health care provider. The marriage of the Principal to the Agent shall not affect this power, but a subsequent divorce, dissolution, or annulment shall automatically revoke the designation of the former spouse as Agent.

3.5 Intellectual Property, Work Product, and Medical Records

Any directives, journals, or health-related data compiled by the Agent in the course of their duties shall be considered "Work Made for Hire" as defined under 17 U.S.C. § 101, and all intellectual property rights therein shall vest in the Principal. The Agent shall maintain the confidentiality of all medical records and shall not disclose such records to third parties except as necessary to facilitate medical treatment or as required by law.

3.6 Representations and Warranties

The Principal represents and warrants that they are of sound mind, eighteen (18) years of age or older, and are executing this instrument voluntarily and under no duress or undue influence. The Principal further warrants that they understand the nature and consequences of granting these powers to the Agent.

3.7 Limitation of Liability and Indemnification

The Agent shall not be liable to the Principal, the Principal's heirs, or the Principal's estate for any costs, losses, or damages resulting from any act or omission performed in good faith and in a manner reasonably believed to be in the best interest of the Principal. The Principal hereby agrees to indemnify and hold the Agent harmless from and against any and all claims, liabilities, or expenses (including reasonable attorney fees) arising out of the Agent’s exercise of the powers granted herein, except in cases of willful misconduct or gross negligence.

3.8 Dispute Resolution and Arbitration

Any controversy or claim arising out of or relating to the interpretation of the Agent's authority under this instrument shall be settled by binding arbitration in [County Name], Ohio, in accordance with the rules of the American Arbitration Association. Judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

3.9 Governing Law and Jurisdiction

This document is executed in the State of Ohio and shall be governed by, construed, and enforced in accordance with the laws of the State of Ohio, specifically Ohio Revised Code Chapter 1337.

3.10 Miscellaneous Provisions

(a) Severability: If any provision of this document is held to be invalid, the remaining provisions shall remain in full force. (b) Counterparts: This instrument may be executed in counterparts, each of which shall be deemed an original. (c) Entire Agreement: This document constitutes the entire agreement regarding the Principal’s health care power of attorney and supersedes any prior oral or written expressions of intent.

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4. EXECUTION & FORMAL SIGNATURE BLOCKS

FOR THE PRINCIPAL: I, the Principal, sign my name to this Health Care Power of Attorney on this date: [Date].

Signature: _____________________________________ Printed Name: [Principal Full Legal Name] Principal Address: [Principal Address]

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WITNESS ATTESTATION (Option 1): (Note: Ohio requires either two witnesses OR a notary. This section provides for witnesses.)

I attest that the Principal signed or acknowledged this Health Care Power of Attorney in my presence and that the Principal appears to be of sound mind and not under or subject to duress, fraud, or undue influence. I am not the Agent, I am not the attending physician, and I am not the administrator of any nursing home where the Principal is receiving care.

Witness 1: Signature: _____________________________________ Printed Name: [Witness 1 Name] Date: [Date]

Witness 2: Signature: _____________________________________ Printed Name: [Witness 2 Name] Date: [Date]

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NOTARY ACKNOWLEDGMENT (Option 2):

STATE OF OHIO COUNTY OF ____________________ ss:

On this _______ day of ___________, 20, before me, the undersigned notary public, personally appeared [Principal Full Legal Name], known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained.

Signature of Notary Public: _____________________________________ My Commission Expires: [Date]

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5. STEP-BY-STEP EXECUTION & FILING GUIDE

Step 1: Customization and Review Open the document in Microsoft Word or Google Docs. Replace all bracketed fields (e.g., [Principal Full Legal Name]) with the accurate, legal names and addresses of the parties. Ensure no brackets remain.

Step 2: Selection of Agent Confirm with your chosen Agent and Successor Agents that they are willing to serve. Provide them with a draft copy for review.

Step 3: Formal Execution Do not sign the document until you are in the presence of either:

• Two (2) qualified witnesses; OR
• A Notary Public. Note: In Ohio, if you use witnesses, at least one must NOT be related to you by blood, marriage, or adoption.

Step 4: Digital Signature (Optional) If using DocuSign or Adobe Sign, ensure the platform provides a "Certificate of Completion" that captures the IP address, timestamp, and audit trail. Note that for health care documents, physical "wet ink" signatures are still preferred by many Ohio hospitals for immediate recognition.

Step 5: Record Retention and Distribution

1. Original: Keep the original in a secure, accessible location (not a safe deposit box that no one can open).
2. Agent: Provide a full copy to your Agent and Successor Agents.
3. Physician: Provide a copy to your primary care physician to be uploaded to your Electronic Medical Record (EMR).
4. Hospital: If scheduled for surgery, provide a copy to the hospital admissions desk.

Step 6: Periodic Audit Review this document every 2–3 years or upon a major life event (marriage, divorce, death of an agent) to ensure the designations remain current with your intent.