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Maryland Durable Medical Power of Attorney Form |
The Maryland Power Of Attorney For Health Care form is a legally binding form that lets a patient choose an agent to decide on the health care treatment they will receive should they no longer be able to make those decisions. This may be due to serious illness, for example, a coma or unconsciousness. The Power Of Attorney document must be observed by two witnesses, one of which can be a notary. The document was created in accordance with §5-601 to –618.
How to Write
Principal
The principal`s details must be entered.
- Name.
- Date of birth.
Designation Of Agent
The principal must choose an agent and alternative agents.
- Name of agents.
- Address of agents.
- Home/Cell telephone numbers of agents.
Powers Of Health Care Agent
The principal must enter the specific conditions and limitations of the powers given the the agent in the relevant blank field.
People The Agent Must Consult
The principal must enter the details of the people who the agent must consult.
- Names.
- Telephone numbers.
Preganancy
The principal must enter the criteria in the relevant blank field for the agent to follow should the principal be found to be pregnant.
Effectiveness Of Agent` Authority
The principal must decide upon how the agent`s authority becomes effective.
- Initial to signify immediate effectiveness of agent`s authority.
- Initial to signify effectiveness of agent`s authority in the event of the principal becoming temporarily or permanently unable to decide themselves.
Statement Of Goals And Values
The principal must specify any details they wish to be carried out regarding treatment during the final part of their life.
Preference In Case Of A Terminal Condition
The principal must choose how they wish to be treated in the event that their condition is deemed to be terminal.
- Initial to refuse any treatment to extend life including artificial hydration and nutrition.
- Initial to refuse any treatment to extend life except for the provision of artificial hydration and nutrition.
- Initial to receive all possible treatments and measures to extend life.
Preference In Case Of A Vegetative State
The principal must choose how they wish to be treated in the event that their condition deteriorates into a vegetative state.
- Initial to refuse any treatment to extend life including artificial hydration and nutrition.
- Initial to refuse any treatment to extend life except for the provision of artificial hydration and nutrition.
- Initial to receive all possible treatments and measures to extend life.
Preference In Case Of An End-Stage Condition
The principal must choose how they wish to be treated in the event of their reaching and end-stage condition.
- Initial to refuse any treatment to extend life including artificial hydration and nutrition.
- Initial to refuse any treatment to extend life except for the provision of artificial hydration and nutrition.
- Initial to receive all possible treatments and measures to extend life.
In Case Of Pregnancy
The principal should enter specific details of how they wish to be treated should they be found to be pregnant.
Effect Of Stated Preferences
The patient must express their decision regarding the following of their specified wishes by the agent and the medical care practitioners.
- Initial to allow flexibility regarding their decisions and wishes as stated.
- Initial to only allow their wishes to be carried out as stated exactly.
Witnesses
The principal must designate witnesses to the Power Of Attorney document.
- Signature of principal.
- Date.
- Signatures of witnesses.
- Telephone numbers of witnesses.
- Date.
After Death
The principal must enter their details.
- Name.
- Date of birth.
Organ Donation
The principal must specify their wishes regarding the donation of organs, tissues and body parts by initialing the particular choices they require and striking through the others.
- Initial to make a donation.
- Initial to donate organs, tissues or eyes.
- Initial to donate only specific items entered by the principal in the relevant blank field.
- Initial to donate for transplantation.
- Initial to donate for therapy.
- Initial to donate for research.
- Initial to donate for medical education.
- Initial to donate for any purpose authorized by law.
- Initial to donate the body, after organ donation, for the purpose of a medical study program.
Disposition Of Body And Funeral Arrangements
The principal must enter directions for their wishes for themselves after their death and the authority for who shall carry out these wishes.
- Initial to give the agent authority over the principal after their death.
OR enter specific details of a nominated person to have authority over the principal after their death.
- Name.
- Address.
- Home/Cell telephone numbers.
The principals specific wishes.
- The principal must describe their personal wishes and conditions for their treatment after death.
Signatures
The personal details of those persons who are involved with this document must be entered.
- Principal`s signature.
- Date.
- Witnesses Signatures.
- Witnesses telephone numbers.
- Date.
