Fillable Printable Health Care Power of Attorney - Maine

Health Care Power of Attorney - Maine

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)

HEALTH CARE POWER OF ATTORNEY of _______________________ Page ___2___

(3) AGENT AND ALTERNATIVE AGENT UNAVAILABLE: If I revoke the authority of

my agent and first alternate agent, if I have named one, or if neither my agent or alternate, if I

have named one, is willing, able or reasonably available to make health-care decisions for me,

the instructions in this health care directive are nevertheless to be followed without need for the

express authorization of an agent. YES____ NO_____

(4) AGENT’S AUTHORITY: My agent is authorized to make all health-care

decisions that in my agent’s judgment relate to psychiatric, psychological and emotional care and

treatment, including the right to consent, withhold consent or withdraw consent to any test,

procedure, program of medications or any form of mental health care and treatment and to select

or discharge any mental health care providers or institutions.

(5) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority

becomes effective when: (Indicate the applicable options)

____ my primary physician, or, if I should be in an emergency room or in a treatment setting,

the attending physician determines that I am unable to make my own health-care decisions.

_____ my primary physician, or, if I should be in an emergency room or in a treatment setting,

the attending physician determines that I meet involuntary hospitalization standards.

_____ my primary physician, or, if I should be in an emergency room or in a treatment setting,

the attending physician determines that if I do not receive psychiatric hospitalization or the

treatment as set out in this instrument my condition will quickly deteriorate such that I would

soon meet the standard for involuntary hospitalization.

______ other. Describe ____________________________________________________

______________________________________________________________________________

The above option(s) require a second physician’s opinion. Yes._____ No _____

I waive the 2

opinion requirement if another physician is not available. Yes _____ No ______

(If I require a second opinion and do not waive the requirement should no second physician be

available, I understand that my advance directive may not become effective.)

HEALTH CARE POWER OF ATTORNEY of __________________________ Page__3__

(6) AGENT’S OBLIGATION: My agent shall make health-care decisions for me in

accordance with this power of attorney for health care and my other wishes to the extent known

to my agent. To the extent my wishes are unknown, my agent shall make health-care decisions

for me in accordance with what the agent determines to be in my best interest. In determining

my best interest, my agent shall consider my personal values to the extent known to my agent.

(7) NOMINATION OF GUARDIAN: (OPTIONAL) If a guardian of my person needs to be

appointed for me by a court, I nominate the following individual to be appointed as my guardian.

__________________________________________ ______________________________

(name of individual) (home phone) (work phone)

________________________________________________________

(address)

________________________________________________________

(city) (state) (zip code)

(8) CHILD CARE ARRANGEMENTS If I am to be admitted to residential care or

to a hospital, or I am otherwise unable to care for my children, and I have not made prior child

care arrangements, I authorize my agent to make those arrangements. If my agent or alternative

is not available, I request that the following individual be contacted to care for my children

temporarily:

__________________________________________ ______________________________

(name of individual) (home phone) (work phone)

________________________________________________________

(address)

________________________________________________________

(city) (state) (zip code)

(9) DESIGNATION OF PRIMARY PHYSICIAN I designate the following as my

primary physician, for the purposes of this directive:

______________________________________________ _______________________

(

name of physician) (phone number)

______________________________________________

(address)

_______________________________________________________________

(city) (state) (zip code)

HEALTH CARE POWER OF ATTORNEY of _______________________ Page ___4___

A COPY OF THIS FORM HAS THE SAME EFFECT AS THE ORIGINAL.

________________________________________ Dated: ______________________________

signature

_________________________________________ ____________________________________

witness signature

_________________________________________ ____________________________________

witness Address witness address

______________________________________________________ ________________________________________________

city state zip code city state zip code

Dated:___________________________________ Dated: ______________________________