Colorado Health Care Power of Attorney Form

The Health care power of attorney form is a very important form when the need arises someone else to take medical decisions on behalf of another person. This is a Colorado health care power of attorney form, it is only applicable in state of Colorado, United States of America. To use this form download it and fill in the details as per your requirements.

A healthcare power of attorney is executed when a person referred to here as the “principal” is unfit to make medical decisions on his own behalf. So in such scenarios another person who may either be close order could be a family member, can take those medical decisions on the principal’s behalf.

In this health care power of attorney form the principal appointments trustworthy person as the “agent” who will take medical decisions on his behalf, if he is unable to do so. For the principal to be deemed unfit to make the medical decisions on his own behalf, the medical findings have to be substantiated by a written certificate given by general physician. This certificate must state that the principal is medically unfit and hence is unable to take medical decisions on his own behalf. Only then can the agent start making decisions on the principal’s behalf.

Though there are a few decisions that the agent cannot take on the principal’s behalf, some of them are, admittance to a mental institution, life-threatening decisions.


Text Version of this Form

———————– Page 1———————–

By this document, I intend to create a Medical Durable
Power of Attorney which shall take effect either (initial
I, ____________________________________ ,
Declarant, hereby appoint:

______ (Initials) Immediately upon my signature.

Name of Agent
______ (Initials) When my physician or other qualified
medical professional has determined that I am unable to
Agent’s Best Contact Telephone Number make my or express my own decisions, and for as long
as I am unable to make or express my own decisions.

Agent’s email or alternative telephone number
My Agent shall make healthcare decisions as I direct
Agent’s home address
below, or as I make known to him or her in some other
way. If I have not expressed a choice about the decision
as my Agent to make and communicate my healthcare
or healthcare in question, my Agent shall base his or her
decisions when I cannot. This gives my Agent the
decisions on what he or she, in consultation with my
power to consent to, or refuse, or stop any healthcare,
healthcare providers, determines is in my best interest. I
treatment, service, or diagnostic procedure. My Agent
also request that my Agent, to the extent possible,
also has the authority to talk with healthcare personnel,
consult me on the decisions and make every effort to
get information, and sign forms as necessary to carry out
those decisions. enable my understanding and find out my preferences.

State here any desires concerning life-sustaining
If the person named above is not available or is unable
procedures, treatment, general care and services,
to continue as my Agent, then I appoint the following
including any special provisions or limitations:
person(s) to serve in the order listed below.

Name of Alternate Agent #1

Agent’s Best Contact Telephone Number

Agent’s email or alternative telephone number

Agent’s home address

Name of Alternate Agent #2

Agent’s Best Contact Telephone Number

Agent’s email or alternative telephone number My signature below indicates that I understand the
purpose and effect of this document:

Agent’s home address

Signature of Declarant Date

Pursuant to Colorado Revised Statute 15-14.503–509 1

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1. Signature of the Appointed Agent 2. Signature of Witnesses and Notary

Although not required by Colorado law, my signature The signature of two witnesses and a notary seal are not
below indicates that I have been informed of my required by Colorado law for proper execution of a
appointment as a Healthcare Agent under Medical Medical Durable Power of Attorney; however, they may
Durable Power of Attorney for (name of Declarant) make the document more acceptable in other states.

. This document was signed by (name of Declarant)

I accept the responsibilities of that appointment, and I
have discussed with the Declarant his or her wishes and
in our presence, and we, in the presence of each other,
preferences for medical care in the event that he or she
and at the Declarant’s request, have signed our names
cannot speak for him- or herself.
below as witnesses. We declare that, at the time the
I understand that I am always to act in accordance with Declarant signed this document, we believe that he or
his or her wishes, not my own, and that I have full she was of sound mind and under no pressure or undue
authority to speak with his or her healthcare providers, influence. We are at least eighteen (18) years old.
examine healthcare records, and sign documents in order
to carry out those wishes. I also understand that my
authority as a Healthcare Agent is only in effect when Signature of Witness
the Declarant is unable to make his or her own decisions
and that it automatically expires at his or her death. Printed Name
If I am an alternate Agent, I understand that my
responsibilities and powers will only take effect if the
primary Agent is unable or unwilling to serve.

Primary Agent’s Signature Signature of Witness

Printed Name
Printed Name


Notary Seal (optional)
Alternate Agent #1 Signature
State of ___________________________

County of }
Printed Name
SUBSCRIBED and sworn to before me by

, the Declarant,


Alternate Agent #2 Signature and

witnesses, as the voluntary act and deed of the Declarant
Printed Name
this day of , 20 .


Notary Public
My commission expires:

Pursuant to Colorado Revised Statute 15-14.503–509 2