Fillable Maine Health Care Advance Directive Form (Page 3 of 14) in pdf

Maine Health Care Advance Directive Form Page 3

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Part 1 – Power of Attorney for Health Care

Instructions:

This part lets you choose another person to make health care decisions for you, either right away or when you

are too sick to choose your own care. The person you choose is called your agent. You may also name a

second and third choice to be your agent, if your first choice is not willing, reasonably available or able to make

decisions for you. If you choose an agent on this form, but do not fill out any other parts of the form, your

agent will be able to:

• Make all health care decisions for you, including decisions regarding tests, surgery and medication;

• Decide whether or not to have food or fluids given to you through tubes or fed into your veins through an

IV;

• Decide whether or not to use treatments or machines to keep you alive or to restart your heart or

breathing;

• Choose who will give you health care and where you will get it, such as hospitals, nursing homes,

assisted living settings, home health, or hospice care; and

• Make any health decision he or she believes would be consistent with your values or in your best interest,

even if it is not listed in the form.

Who can be your agent:

You can name any adult you trust to be your agent, except your agent may not be the owner, operator or

employee of a nursing home or residential long-term care facility where you are receiving care, unless that

person is your relative.

How your agent must make decisions:

If your agent does not know what you want, the agent must make decisions consistent with your personal

values, if known, or based on your best interests. In Part 2, you can decide what you want in advance. If you

make choices in Part 2, your agent must make decisions based on those choices.

Who can see your health care information:

Once your agent has the right to make health care decisions for you, your agent can look at your medical

records and consent to giving your medical information to others. The state and federal privacy laws let your

agent see all of your health information so that he or she can make the right decision for you.

The first part of your advance directive begins on the next page.

Page 3 of 14

Revised February 2008

Maine Health Care Advance Directive Form Page 3

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