Health Care Power Of Attorney

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HEALTH CARE POWER OF ATTORNEY
Under the Uniform Health Care Decisions Act
18-A M.R.S.A. § 5-801 et seq.
I,
currently of
,
,
name
street address
city
Maine, whose birth date is
, execute this Health Care Power of Attorney so
that I might obtain mental health care and treatment.
(1)
DESIGNATION OF AGENT: I, designate the following individual as my agent
to make mental health-care decisions for me:
(name of individual)
(home phone)
(work phone)
(address)
(city)
(state)
(zip code)
(2)
DESIGNATION OF ALTERNATIVE AGENT: (OPTIONAL) If I revoke this
agent’s authority or if my agent is not willing, able or reasonably available to make mental health
care decisions for me, I designate as my first alternate agent:
(
name of individual)
(home phone)
(work phone)
(address)
(city)
(state)
(zip code)

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