Maine Health Care Advance Directive Form Page 9
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14Part 3 — Primary Physician
This section is optional. Fill out this part only if you wish to name your primary physician today.
Name of my primary physician:__________________________________________________________
Address: _____________________________________________ Phone: ________________________
I want any agent I named in Part 1 to talk with this physician about my health care. If the physician I have
named above is not willing, reasonably available or able to carry out my wishes, I want the agent I named in
Part 1 to talk with the physician listed below:
Name of physician: _____________________________________________________________
Address:_____________________________________________ Phone:___________________
If you want your agent or those making decisions for you to speak with a nurse practitioner or physician
assistant before making a decision, you may complete the following section:
Name of nurse practitioner or physician assistant: _____________________________________
Address: _____________________________________________ Phone:___________________
Page 9 of 14
Revised February 2008
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