Health Care Power Of Attorney
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12M
M
A
D
:
ARYLAND
D
DVANC
CE
IRECT
TIVE
P
F
H
C
D
LANNING
G FOR
UT
TURE
EAL
LTH
ARE
E
ECISION
NS
By:
Date
of Birth:
(Print Name)
(Month/Day/
/Year)
Usi
ing this adv
vance direc
ctive form to
o do health
h care plann
ning is com
mpletely
optional
l. Other form
ms are also
o valid in M
Maryland. N
No matter w
what form y
you use, talk
k to
your fam
mily and oth
hers close t
to you abou
ut your wish
hes.
Thi
is form has
two parts t
to state you
ur wishes, a
and a third
part for ne
eeded
signatur
res. Part I o
f this form
lets you an
nswer this q
question: If
you cannot
t (or do not
t
want to)
) make you
r own healt
th care deci
isions, who
o do you wa
ant to make
e them for y
you?
The pers
son you pic
ck is called
your health
h care agen
nt. Make su
ure you talk
k to your he
ealth
care age
ent (and any
y back‐up a
agents) abo
out this im
mportant rol
le. Part II le
ets you writ
te
your pre
eferences ab
bout efforts
s to extend
your life in
n three situa
ations: term
minal condit
tion,
persisten
nt vegetativ
ve state, and
d end‐stage
e condition
n. In additio
on to your h
health care
planning
g decisions
, you can ch
hoose to be
ecome an or
rgan donor
r after your
death by
filling ou
ut the form
m for that too
o.
➔ You
u can fill ou
ut Parts I an
nd II of this
s form, or o
only Part I, o
or only Par
rt II. Use the
e
form to
reflect your
r wishes, th
hen sign in
front of two
o witnesses
s (Part III).
If your wis
shes
change,
make a new
w advance
directive.
»
Ma
ake sure you
u give a cop
py of the co
ompleted fo
orm to your
r health car
re agent, yo
our
doctor, a
and others
who might
t need it. Ke
eep a copy
at home in
a place wh
here someon
ne
can get i
it if needed
d. Review w
what you ha
ave written
periodical
lly.
P
I:
S
H
C
A
ART
ELECTION
N OF
EALT
TH
ARE
G
GENT
A
A. Selectio
on of Prima
ary Agent
I select t
the followin
ng individu
ual as my ag
gent to mak
ke health ca
are decision
ns for me:
Name:
Address
s:
Telepho
one Numbe
ers:
(home and ce
ell)
Pa
age 1 of 8
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Parent category: Legal