South Carolina Medical Power of Attorney
This South Carolina Medical Power of Attorney is a crucial legal document that grants an appointed individual (Agent) the authority to make health care decisions on behalf of the person executing the document (Principal), in accordance with South Carolina Health Care Power of Attorney Act, when the Principal is unable to make these decisions themselves.
Principal Information
Full Name: ___________________________________
Date of Birth: ________________________________
Address: _____________________________________
Agent Information
Full Name: ___________________________________
Relationship to Principal: _____________________
Primary Phone: _______________________________
Alternate Phone: _____________________________
Email Address: _______________________________
Address: _____________________________________
Alternate Agent Information (In case the primary Agent is unable or unwilling to act)
Full Name: ___________________________________
Relationship to Principal: _____________________
Primary Phone: _______________________________
Alternate Phone: _____________________________
Email Address: _______________________________
Address: _____________________________________
Special Instructions
Here, the Principal can specify preferences, limitations, or special directions for the Agent that they would like to be adhered to when making health care decisions:
Instructions: __________________________________________________________
_______________________________________________________________________
Effective Date and Signatures
This Medical Power of Attorney becomes effective upon the incapacity of the Principal to make health care decisions as certified by a physician.
Principal's Signature: ___________________________ Date: ________________
Agent's Signature: _____________________________ Date: ________________
Alternate Agent's Signature: ____________________ Date: ________________
Witnesses
State law requires two adult witnesses to the Principal's signature. Witnesses must not be related to the Principal, entitled to any part of the estate of the Principal, directly financially responsible for the Principal's medical care, or agents appointed in this document.
Witness 1 Signature: ___________________________ Date: ________________
Print Name: ___________________________________
Address: _____________________________________
Witness 2 Signature: ___________________________ Date: ________________
Print Name: ___________________________________
Address: _____________________________________
Notarization (If required)
This section should be completed by a Notary Public if notarization is necessary or desired for added legal certainty.
In front of a Notary Public:
- Principal's Signature
- Agent's Signature
- Alternate Agent's Signature
Notary Public's Signature and Seal: _______________________________________
Date: _________________