Living Will Forms > Free Maine Living Will Forms | Advance Health Care Directive > Maine Durable Medical Power of Attorney Form

Maine Durable Medical Power of Attorney Form

The Maine medical power of attorney form is created in 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, or illnesses such as a coma, their wishes may still be carried out. It also covers the decisions regarding end-of-life treatment.

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.