Maine Health Care Advance Directive Form Page 5
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14Your agent’s power:
When your agent can start making decisions for you: (Check only one box: A or B)
A.
My agent can make decisions only when my primary physician or a judge decides that I am too sick to
make my own health care decisions.
OR
B.
My agent can start making health care decisions for me right away, but this does not mean I have given
up the right to make my own decisions if I am still able and willing to make my own decisions. When my agent
makes a health care decision for me, I will be told, if possible, about that decision before it is carried out unless
I say I do not want to know. If I disagree with that decision and am still able to decide, I can make a different
decision. As long as I am able, I can end my agent’s right to make decisions for me, change my agent or make
my own decisions. If I want to end my agent’s right to make decisions for me, I must tell my primary physician
or put my decision in writing and sign it with the date of my signature.
Nominating a guardian:
A guardian is a person chosen by a court to make decisions about your personal care. These decisions can
include not only health care, but other decisions such as where you will live and how your personal needs will
be met. If you wish, you may ask that a court assign your agent as your guardian, if appointment of a guardian
should become necessary. Check the box below to nominate your agent to be your guardian, if a judge needs to
appoint a guardian for you.
I nominate my agent to be my guardian if a judge needs to appoint a guardian for me.
If you want to nominate someone other than your agent to be your guardian, you may fill in the section
below.
If a judge needs to appoint a guardian for me, I nominate the person named below as my guardian:
Name__________________________________________ Title or Relationship to me________________
Address______________________________________________________________________________
_____________________________________________________________________________________
Home Phone (___)_______________________ Work Phone (___)______________________________
Page 5 of 14
Revised February 2008
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