Maine Durable Medical Power of Attorney Form

The Maine medical power of attorney form is created accordance with the US Statutes tit. 18- A, § 5-801 to -817 for the principal to designate an appointed agent so that in the event of them becoming incapacitated through illness, illnesses such as a coma, their wishes may still be carried out. It also also covers the decisions regarding end of life treatment. It is not legally valid as a document if the principal is pregnant.

How to Write

Principal

The principal must enter their personal details.

  • Name.
  • Address.
  • Date of birth.

NOTE: The principal must Name/Sign the top of each individual page in the blank fields provided.

 

Agent

1 & 2) The agent`s details and alternative agent`s details must be entered.

  • Name.
  • Address.
  • ZIP code.
  • Home/Work telephone numbers.

 

In Event Of NO Agents

3) Initial either `Yes` or `No` to give authority regardless of the presence of an agent.

 

Effectiveness Of Agent`s Authority

5) The principal must choose when the agent`s authority becomes effective.

  • Initial to signify effect of authority should the principal no longer  be able to decide.
  • Initial to signify effect of authority should the principal meet involuntary hospitalization standards.
  • Initial to signify effect of authority should the principal would be expected to soon meet involuntary hospitalization standards.
  • Initial and enter specific details regarding when the authority of the agent becomes effective.
  • Initial `Yes` or `No` to signify the requirement of a physicians opinion.
  • Initial `Yes` or `No to waive the requirement for a second opinion should one not be available.

 

Nomination Of Guardian (Optional)

7) The principal has the option to nominate a guardian.

  • Guardian`s name.
  • Guardian`s address.
  • Guardian`s ZIP code.
  • Guardian`s Home/Work telephone numbers.

 

Child Care Arrangements

8) The principal must designate a person to be contacted for the care of their children.

  • Nominee`s name.
  • Nominee`s address.
  • Nominee`s ZIP code.
  • Nominee`s home/work telephone number.

 

Designation Of Primary Physician

1) The principal designates a primary physician for the purpose of this document.

  • Physician`s name.
  • Physician`s address.
  • Physician`s ZIP code.
  • Physician`s home/work telephone number.

 

Signatures

Details of the persons involved with this document must be entered.

  • Principal`s signature.
  • Witnesses signatures.
  • Witnesses addresses.
  • Witnesses ZIP codes.
  • Date.