Ohio Medical Power Of Attorney

Information you will need

• Principal Name
• Principal DOB
• Agent Name/Relationship
• Agent Address
• Agent Phone Number
• Protected Health Care Information
• Alternate Agent Name/Relationship
• Alternate Agent Address
• Alternate Agent Phone Number
• Second Alternate Agent Name/Relationship
• Second Alternate Agent Address
• Second Alternate Agent Phone Number
• Special Instructions No Living Will
• Additional Instructions/Limitations
• Guardian of Person
• Guardian of Person Name/Relationship
• Guardian of Person Address
• Guardian of Person Phone Number
• Alternate Guardian of Person Name/Relationship
• Alternate Guardian of Person Address
• Alternate Guardian of Person Phone Number
• Guardian of Estate
• Guardian of Estate Name/Relationship
• Guardian of Estate Address

…and 21 more fields in the PDF.

Completed by the agent and the principal and the employee.

The form includes a notary acknowledgment, a witness section.