Maine Power Of Attorney For Health Care Will To Live Form printable pdf download

Maine Power of Attorney for Health Care

Will to Live Form

I, (your name)__________________________________________________________________

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

designate:

(Name of agent)________________________________________________________________

(address of agent)_______________________________________________________________

(phone number(s) of agent)________________________________________________________

as my health care agent to make any health care decisions for me as authorized in this document

consistent with the instructions below.

If the person I appoint above refuses or is not able to act for me, I appoint the following persons

(each to act alone and successively, in the order named):

A. First Successor Agent

(successor agent’s name)_________________________________________________________

(successor agent’s address)________________________________________________________

_____________________________________________________________________________

(successor agent’s phone number)__________________________________________________

B. Second Successor Agent

(second successor agent’s name)___________________________________________________

(second successor agent’s address)__________________________________________________

______________________________________________________________________________

(second successor agent’s phone number)____________________________________________

as my health care agent to make any health care decisions for me as authorized in this document

consistent with the instructions below.

This designation shall become effective when it is communicated to my attending physician and

it is determined by my attending physician that I am no longer able to make or communicate

decisions regarding administration of life-sustaining treatment and that I have an incurable and

irreversible condition that without the administration of life-sustaining treatment will, in the

opinion of my attending physician, result in my death within a relatively short time.

Any prior designation is revoked.

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Maine Power Of Attorney For Health Care Will To Live Form