Maine Health Care Advance Directive Form Page 4
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14YOUR ADVANCE DIRECTIVE BEGINS HERE
Choosing an agent: Fill in your name and the name of the person you choose to be your agent to make health
care decisions for you here:
My name______________________________________________________________________________
My agent’s name________________________________________________________________________
Title or relationship to me_________________________________________________________________
My agent’s address______________________________________________________________________
My agent’s home phone (___)___________________ My agent’s work phone (___)__________________
If the agent I have named above is not willing,
If the person I have named as Choice # 2 is not
reasonably available or able to make decisions for
willing, reasonably available or able to make
me, I choose the following person to be my agent:
decisions for me, I choose the following person
to be my agent:
Choice # 2 to be my agent
Choice # 3 to be my agent
Name____________________________________
Name_________________________________
Title or Relationship to me___________________
Title or Relationship to me________________
Address__________________________________
Address_______________________________
_________________________________________
______________________________________
Home Phone (___)__________________________
Home Phone (___)_______________________
Work Phone (___)__________________________
Work Phone (___)_______________________
You may change your mind later about who you want to be your agent. If you want to stop the agent you have
named from making decisions for you, you must tell your primary physician or fill in these blanks:
I do not want ________________________ to be my agent. _______________________________________
My signature
Date you filled out and signed this section _________________________
Any time you cancel, replace or change this form you should give copies of the changed or new form to
everyone who has a copy of your original form.
Page 4 of 14
Revised February 2008
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