Power of Attorney
Power of Attorney
Embedded Files
For Child Care (under Michigan Law)
We, [parent 1’s name] and [parent 2’s name] of [city], Michigan, make, constitute, and appoint [attorney-in-fact 1’s name] or [attorney-in-fact 2’s name] as Attorney-in-Fact for us. Our Attorney-in-Fact is authorized to act in our name, place, and stead for the purpose of exercising our parental rights and powers regarding the care, custody, or property of our child, [child’s name]. We direct that either Attorney-in-Fact may act severally and individually.
We grant to our Attorney-in-Fact the power to authorize and consent to the performance of all necessary medical treatment—including but not limited to necessary treatments, medications, operations, diagnostic procedures, and the administration of general or local anesthesia—by any medical doctors, technicians, assistants, nurses, and other qualified medical personnel that our Attorney-in-Fact deems appropriate.
We grant to our Attorney-in-Fact the power to do and perform all matters as well as to make, execute, and acknowledge all authorizations and documents that are reasonable or proper with the same powers and validity as we could, if personally present, with full power of substitution regarding the property, general health, and well-being of [child’s name].
This power of attorney delegating parental consent is given pursuant to MCL 700.5103.
We ratify and confirm all that our Attorney-in-Fact lawfully does or causes to be done by virtue of this power of attorney.
Dated: [date]
[Signature line]
[Typed name]
Dated: [date]
[Signature line]
[Typed name]
STATE OF MICHIGAN
[COUNTY] COUNTY
)
)
Acknowledged [before me in [county] County, Michigan, / before me using an electronic notarization system under MCL 55.286a in [county] County, Michigan, / before me using a remote electronic notarization platform under MCL 55.286b] on [date], by [name of person acknowledged].
[Signature line]
[Notary public’s name, as it appears on application for commission]
Notary public, State of Michigan, County of [county].
My commission expires [date].
[If acting in county other than county of commission: Acting in the County of [county].]
DURABLE POWER OF ATTORNEY - EFFECTIVE ON EXECUTION (under Michigan Law)
I, , a [married / unmarried] [man / woman] who resides at [address, city, and county], Michigan, designate as my attorney in fact (the agent) on the following terms and conditions:
Authority to act. The agent is authorized to act as a fiduciary for me under this power of attorney and shall exercise all powers in my best interests and for my welfare.
Powers of the agent. The agent may perform any act and exercise any power with regard to my property and affairs that I could do personally, including exercising all of the specific powers set forth below:
Collection and management. Collect, hold, maintain, improve, invest, lease, or otherwise manage any or all of my real or personal property or any interest in it.
Buying and selling. Purchase, sell, mortgage, grant options, or otherwise deal in any way with any real property, including real property described on the attached schedule; personal property, tangible or intangible; or any interest in it, on whatever terms the agent considers to be proper, including the power to buy U.S. Treasury Bonds that may be redeemed at par; to pay federal estate tax; and to sell or transfer treasury securities.
Borrowing. Borrow money, execute promissory notes, and secure any obligation by mortgage or pledge.
Business. Conduct and participate in any kind of lawful business of any nature, including the right to sign partnership agreements; continue, reorganize, merge, consolidate, recapitalize, close, liquidate, sell, or dissolve any business; and vote, assign, sell, or transfer stock, including the exercise of any stock options and the carrying out of any buy-sell agreement.
Banking. Receive and endorse checks and other negotiable paper and deposit and withdraw funds (by check or withdrawal slip) that I now have on deposit or to which I may be entitled in the future, in or from any bank, savings and loan, or other institution.
Tax returns and reports. Prepare, sign, and file separate or joint income, gift, and other tax returns and other governmental reports and documents; consent to any gift; file any claim for a tax refund; and represent me in all matters before the Internal Revenue Service.
Safe-deposit boxes. Have access to and remove any property or papers from any safe-deposit box registered in my name alone or jointly with others.
Proxy rights. Act as my agent or proxy for any stocks, bonds, shares, or other investments, rights, or interests I may hold now or in the future.
Government benefits. Apply to any governmental agency for any benefit or government obligation to which I may be entitled.
Employment benefits. Make, exercise, waive, or consent to any and all elections and/or options that I may have regarding any benefits provided or available to me through my employment.
Legal and administrative proceedings. Engage in any administrative or legal proceedings or lawsuits in connection with any matter under this power.
Life insurance. Exercise any incidents of ownership I may possess with respect to policies of insurance, except policies insuring the life of my agent.
Transfers in trust. Transfer any interest I may have in property, whether real or personal, tangible or intangible, to the trustee of any trust that I have created for my benefit.
Delegation of authority. Engage and dismiss agents, counsel, and employees, in connection with any matter, on whatever terms my agent determines.
Restrictions on the agent’s powers. Regardless of the above statements, my agent (1) may not execute a will, a codicil, or any will substitute on my behalf; (2) may not change the beneficiary on any life insurance policy that I own; (3) may not make gifts on my behalf; and (4) may not exercise any powers that would cause assets of mine to be considered taxable to my agent or to my agent’s estate for purposes of any income, estate, or inheritance tax.
Durability. This power of attorney is not affected by my subsequent disability or incapacity, or by the lapse of time, and it shall continue in effect until my death or until I revoke it in writing. The agent shall have no duty to act and shall incur no liability to me or to my estate for failing to take any action under this power of attorney before receiving written notice from me requesting the agent to act or, alternatively, receiving written notice that, in the opinion of two licensed physicians, I am unable to act due to either disability or incapacity, in which case the agent shall immediately begin to act.
Reliance by third parties. Third parties may rely on the representations of the agent in all matters regarding powers granted to the agent. No person who acts in reliance on the representations of the agent or the authority granted under this power of attorney shall incur any liability to me or to my estate for permitting the agent to exercise any power before actual knowledge that the power of attorney has been revoked or terminated by operation of law or otherwise.
Indemnification of the agent. No agent named or substituted in this power shall incur any liability to me for acting or refraining from acting under this power, except for that agent’s own misconduct or negligence.
Original counterparts. Photocopies or facsimile reproductions of this signed power of attorney shall be treated as original counterparts.
Revocation. I revoke any previous power of attorney that I may have given to deal with my property and affairs as stated in this document.
Compensation. The agent shall be reimbursed for reasonable expenses incurred while acting as agent and may receive reasonable compensation for acting as agent.
Governing Law. This document shall be governed by the laws of the State of Michigan.
Appointment of fiduciary by court. I nominate to serve as guardian over my person and conservator over my estate if a protective proceeding over my person or estate is commenced after the execution of this power of attorney. If is unable or unwilling to act, I nominate to serve in [his / her] place.
Substitute agent. If is, at any time, unable or unwilling to act, I then appoint as my agent.
Dated:
[Typed name]
[Address, telephone]
Witness 1
Dated:
/s/
[Typed name]
[Address, telephone]
Witness 2
Dated:
/s/
[Typed name]
[Address, telephone]
STATE OF MICHIGAN
[COUNTY] COUNTY
)
)
Acknowledged [before me in [county] County, Michigan, / before me using an electronic notarization system under MCL 55.286a in [county] County, Michigan, / before me using a remote electronic notarization platform under MCL 55.286b] on [date], by [name of person acknowledged].
[Signature line]
[Notary public’s name, as it appears on application for commission]
Notary public, State of Michigan, County of [county].
My commission expires [date].
[If acting in county other than county of commission: Acting in the County of [county].]
Acknowledgment of Duties Under a Durable Power of Attorney
I, [attorney-in-fact], have been appointed as the attorney-in-fact for [principal], the principal, under a durable power of attorney dated [date]. By signing this document, I acknowledge that if and when I act as attorney-in-fact, all of the following apply:
Except as provided in the durable power of attorney, I must act in accordance with the standards of care applicable to fiduciaries acting under durable powers of attorney.
I must take reasonable steps to follow the instructions of [principal].
On the request of [principal], I must keep [principal] informed of my actions. I must provide an accounting to [principal] on the request of the principal, to a guardian or conservator appointed on behalf of [principal] on the request of that guardian or conservator, or pursuant to judicial order.
I cannot make a gift from [principal]’s property, unless provided for in the durable power of attorney or by judicial order.
Unless provided in the durable power of attorney or by judicial order, I, while acting as attorney-in-fact, will not create an account or other asset in joint tenancy between the principal and me.
I must maintain records of my transactions as attorney-in-fact, including receipts, disbursements, and investments.
I may be liable for any damage or loss to [principal], and may be subject to any other available remedy, for a breach of fiduciary duty owed to the principal. In the durable power of attorney, the principal may exonerate me of any liability to the principal for a breach of fiduciary duty except for actions committed by me in bad faith or with reckless indifference. An exoneration clause is not enforceable if inserted as the result of my abuse of a fiduciary or confidential relationship to the principal.
I may be subject to civil or criminal penalties if I violate my duties to [principal].
Dated:
[Typed name]
Health Care Power of Attorney - Designation of Patient Advocate
I, [name], live at [address]. This document is my health care power of attorney. In section 1, I designate my patient advocate (my agent). In section 2, I grant to my agent certain powers, subject to the restrictions in section 3.
1. Designation of Agent. I name [agent] as my agent. If [agent] dies or is not able and willing to act as my agent under this health care power of attorney, I name [successor agent] as my agent.
2. Agent’s Powers. I grant to my agent the powers in this section 2, subject to the restrictions in section 3.
2A. Obtain Access to My Medical and Other Personal Information. My agent shall have the power to access, request, obtain, review, examine, inspect, receive, copy, use, and disclose all information, documents, records, and protected health information, verbal or written, regarding my personal affairs or my care, custody, medical treatment, or mental health treatment. My agent shall have the power to execute any releases or other documents that may be required to obtain this information.
2B. Release Medical Records. My agent shall have the power to authorize one or more of the physicians, dentists, nurses, therapists, other professionals, hospitals, and other institutions who have provided me with care, custody, medical treatment, or mental health treatment to release information, documents, records, and protected health information concerning my care, custody, medical treatment, or mental health treatment to any person or entity designated by my agent.
2C. Apply for Benefits. My agent shall have the power to apply for (and appeal any denial of) private, public, government, or veterans benefits (including, without limitation, Medicare or Medicaid) for me to defray the costs of my care, custody, medical treatment, or mental health treatment. My agent shall have access to information regarding my income, assets, banking, and financial records to the extent required to make such an application.
2D. Employ and Discharge Certain Professionals. My agent shall have the power to employ or discharge physicians, psychiatrists, dentists, nurses, therapists, or other professionals as my agent determines for my medical treatment, my mental health treatment, or my physical, mental, or emotional care or well-being. My agent shall have the power to pay professionals reasonable compensation from my assets.
2E. Consent or Refuse Consent to My Medical Treatment. My agent shall have the power to give or withhold consent to my care, custody, or medical treatment, including but not limited to surgery, chiropractic treatment, physical therapy, other medical procedures, tests, hospitalization, convalescent care, or home care. My agent shall have the power to revoke, withdraw, modify, or change any consent regarding my care, custody, or medical treatment (including but not limited to consent regarding surgery, chiropractic treatment, physical therapy, other medical procedures, tests, hospitalization, convalescent care, or home care) that I or my agent may have previously given or any consent that may have been implied due to emergency conditions. I have told my agent about my personal preferences regarding my care, custody, or medical treatment. My agent shall also have the power to summon paramedics or other emergency medical personnel and seek emergency treatment for me, or choose not to do so, as my agent determines. My agent shall have the power to authorize a “Refusal to Permit Treatment” or a “Leaving Hospital Against Medical Advice” for me. My agent shall have the power to authorize waivers or releases from liability that may be required by a hospital or physician to implement my desires regarding medical treatment or nontreatment. This section shall not apply to my mental health treatment.
2F. Consent or Refuse Consent to My Mental Health Treatment. On the execution of a certificate of two independent psychiatrists who have examined me and who are licensed to practice in the state of my residence, which certificate states that in their opinions I am unable to give informed consent to mental health treatment decisions concerning me, my agent shall have the power to make mental health treatment decisions for me, including to arrange for private psychiatric or psychological treatment for me; to arrange for hospitalization for me as provided in the next sentence; to refuse consent for hospitalization, institutionalization, or private psychiatric or psychological care; and to revoke, modify, withdraw, or change any consent regarding hospitalization, institutionalization, or private treatment that I or my agent may have previously given. On the execution of a certificate of two independent psychiatrists who have examined me and who are licensed to practice in the state of my residence, which certificate states that in their opinions I am in immediate need of hospitalization because of mental disorders or substance abuse, my agent shall have the power to arrange for my voluntary admission to an appropriate hospital or institution for treatment of the diagnosed problem or disorder.
2G. Refuse Life-Prolonging Procedures. My agent shall have the power to request that life-prolonging procedures be discontinued or not be instituted for me should my agent determine that such procedures would serve only to prolong artificially the process of dying. Consistent with the previous sentence, my agent has the authority to withdraw or withhold treatment that would allow me to die, and I acknowledge that such a decision could or would result in my death. My agent shall have the power to specifically request, and concur with, the writing of a “no-code (do-not-resuscitate)” order by the attending or treating physician. I authorize my agent to create physician orders for scope of treatment or any similar form (collectively, “POST”) for me and to elect on any POST an option to withhold or withdraw treatment that could or would allow me to die. If I sign a POST in the future, I direct that the treatment options I selected in the POST shall control.
2H. Provide Me Relief from Pain. My agent shall have the power to consent to, and arrange for, the administration of pain-relieving drugs of any type or other surgical or medical procedures calculated to relieve my pain, even though their use may lead to permanent physical damage, addiction, or hasten the moment of (but not intentionally cause) my death. My agent shall also have the power to consent to, and arrange for, unconventional pain-relief therapies for me such as biofeedback, guided imagery, relaxation therapy, acupuncture, hydrotherapy, massage therapy, skin stimulation, or other therapies that I or my agent believes may be helpful.
2I. Protect My Right of Privacy. My agent shall have the power to exercise my right of privacy to make decisions regarding my medical treatment and my right to be left alone, even though the exercise of my right might hasten my death or be against conventional medical advice. My agent shall have the power to take appropriate legal action, if necessary in my agent’s judgment, to enforce my right in this regard. I authorize my agent to make any decision permitted under this health care power of attorney, even if the decision could or would result in my death.
2J. Donation of Organs or Body. To the extent that I have not previously indicated in an organ donor card or otherwise to the contrary, my agent shall have the power (before or after my death) to consent to the donation on my death of any or all of my organs, or to the donation on my death of my body to a medical school or other institution for medical training or scientific research, or to modify or revoke any previous consent given by my agent for the donation of my organs or my body. However, my agent shall not have the power to modify or revoke a previous consent to donate my organs or my body that was signed by me.
3. Restrictions on Agent’s Powers. Except for the powers in sections 2A, 2B, 2C, and 2D, the powers granted to my agent under this health care power of attorney shall be exercisable only if I am unable to participate in medical treatment or mental health treatment decisions. My agent’s power pursuant to section 2J shall be exercisable after my death.
4. Interpretation. This health care power of attorney is to be effective notwithstanding my subsequent disability or incapacity or the lapse of time. This health care power of attorney is intended to be clear and convincing evidence of my intent concerning my medical treatment and mental health treatment. It is my intent that my agent has the fullest authority to make medical treatment and mental health treatment decisions on my behalf as may be permitted under this health care power of attorney, regardless of the state or country in which I may be located. This health care power of attorney shall be construed consistent with my intent. The terms patient advocate and agent shall be deemed to include patient advocate, health care surrogate, health care proxy, or any similar designation as used in any state or country.
5. Nomination of Guardian. If a court determines that a guardian of my person should be appointed for me, I nominate my agent as guardian of my person.
6. Third-Party Reliance; Photographic Copies. Third parties may rely in good faith on the representation of my agent in a written certificate signed by my agent that this health care power of attorney has not been revoked before the third party’s actual knowledge that this health care power of attorney has been revoked. Photographic or other facsimile reproductions of this health care power of attorney may be made and delivered by my agent and may be relied on by any person to the same extent as though the copy were an original. A third party who acts in reliance on a representation or certificate from my agent, or on a photographic or facsimile copy of this health care power of attorney, shall not be liable for releasing my health care information to my agent.
7. Revocation. I retain the right to revoke this authorization at any time and in any manner sufficient to communicate an intent to revoke.
8. Notice. Any notice required or permitted to be delivered under this health care power of attorney shall be deemed to have been adequately delivered if delivered personally, delivered by courier, sent by first-class mail, sent by certified mail, sent by private delivery service, or sent by properly directed and identified facsimile or other electronic transmission. The notice shall be delivered or sent to the last known residence or business address (or facsimile or electronic address) of the recipient as disclosed in my records. Such notice shall be deemed to have been received by the recipient two days after being delivered or sent pursuant to this section.
9. Revocation of Prior Agent. I revoke all prior health care powers of attorney, durable powers of attorney for health care, designations of patient advocate, designations of health care surrogate, designations of health care proxy, or similar documents dealing with my medical treatment or mental health treatment. This section shall not apply to any durable power of attorney for my financial affairs.
I have signed this health care power of attorney on [date].
[Signature line]
[Typed name]
Witness
Dated: [date]
[Signature line]
[Typed name]
Witness
Dated: [date]
[Signature line]
[Typed name]
Acceptance of Patient Advocate Designation
I accept the designation by [patient] (patient) as a patient advocate pursuant to the following:
This patient advocate designation is not effective unless the patient is unable to participate in decisions regarding the patient’s medical or mental health, as applicable. If this patient advocate designation includes the authority to make an anatomical gift as described in MCL 700.5506, the authority remains after the patient’s death.
A patient advocate shall not exercise powers concerning the patient’s care, custody, and medical or mental health treatment that the patient, if the patient were able to participate in the decision, could not have exercised on the patient’s own behalf.
This patient advocate designation cannot be used to make a medical treatment decision to withhold or withdraw treatment from a patient who is pregnant that would result in the pregnant patient’s death.
A patient advocate may make a decision to withhold or withdraw treatment that would allow a patient to die only if the patient has expressed in a clear and convincing manner that the patient advocate is authorized to make such a decision, and that the patient acknowledges that such a decision could or would allow the patient’s death.
A patient advocate shall not receive compensation for the performance of the patient advocate’s authority, rights, and responsibilities, but a patient advocate may be reimbursed for actual and necessary expenses incurred in the performance of the patient advocate’s authority, rights, and responsibilities.
A patient advocate shall act in accordance with the standards of care applicable to fiduciaries when acting for the patient and shall act consistent with the patient’s best interests. The known desires of the patient expressed or evidenced while the patient is able to participate in medical or mental health treatment decisions are presumed to be in the patient’s best interests.
A patient may revoke the patient’s patient advocate designation at any time and in any manner sufficient to communicate an intent to revoke.
A patient may waive the patient’s right to revoke the patient advocate designation as to the power to make mental health treatment decisions, and if the waiver is made, the patient’s ability to revoke as to certain treatment will be delayed for 30 days after the patient communicates the patient’s intent to revoke.
A patient advocate may revoke the patient advocate’s acceptance of the patient advocate designation at any time and in any manner sufficient to communicate an intent to revoke.
A patient admitted to a health facility or agency has the rights enumerated in section 20201 of the Public Health Code, 1978 PA 368, MCL 333.20201.
Dated: [date]
[Signature line]
[Typed name]
Page updated
Report abuse