Fillable Maine Health Care Advance Directive Form (Page 12 of 14) in pdf

Part 6—Signing the Form

If you have filled out any part of this form, you must sign and date the form on this page. You must also have two

other adults sign as witnesses at the same time you sign the form. Your agent cannot sign as a witness. You do not

need to have a Notary Public sign your Advance Directive form to make it legal in Maine. However, if you travel or

live part of the year out-of-state, it would be wise to have it signed by a Notary. Some states require this. You can

find this service under Notary Public in the phone book. Most banks also have Notaries Public and will usually

notarize papers for bank customers when asked. The Notary Acknowledgment may be done at any time after you

sign this form.

Sign and date the form here:

Sign your name: _________________________

Your Address:_________________________________

Print your name: _________________________

_____________________________________________

Date: __________________________________

_____________________________________________

First witness:

Signature: ______________________________

Address: _____________________________________

Print your name: ________________________

________________________________________________

Date: __________________________________ ________________________________________________

Second witness:

Signature: ______________________________

Address: _____________________________________

Print your name: ________________________

________________________________________________

Date: __________________________________ ________________________________________________

Notary Acknowledgment.

Then personally appeared the above named __________________________________, known to me or who

presented satisfactory evidence of his/her identity, and acknowledged this Advance Directive as his/her free act and

deed before me.

Notary signature: _______________________________________________

Date: ___________________

Printed name: ______________________ Notary Public State of:___________ Commission Exp.: _________

Make sure to tell people. Tell your family members, physicians and others close to you what you have decided.

You should talk to the agent(s) you have chosen to make sure that they understand your wishes and are willing to

carry them out. Give a copy of this form to your physician, to any place where you get health care, and to any

agent(s) you have chosen in Part 1. Please be sure to list the people who have copies of this form on the front page .

Canceling or changing the form.

Part 1: You may end your agent’s right to make decisions while you are still able to make those decisions by telling

your primary physician or putting your decision in writing and attaching it to this form. If you want to name a new

agent, you must put that instruction in writing and sign it in front of two witnesses who must also sign their names .

Parts 2-7: You may cancel any other part of this form, or change your instructions in the other parts of this form

while you are still able to make those decisions. It is best to do so by (1) writing on this form, (2) writing on another

piece of paper and attaching it to this form, or (3) completing a new form. Any of those written changes should be

signed and dated by you.

Page 12 of 14

Revised February 2008

Maine Health Care Advance Directive Form Page 12

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