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Maryland ____________________ Phone: _______________________________________ Date: ________________ -3- _________________________________ Date: ________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: __________________petent individual. -2- _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: ______ benefit by reason of Declarant's death). The declarant signed or acknowledged signing this appointment of a health care agent in my presence and based upon my personal observation appears to be a comd its purpose and effect. ______________________ (Date) ____________________________________________ (Signature of Declarant) (At least one of your witnesses may not be a person who may financiallyor the costs of care based solely on this authorization. By signing below, I indicate that I am emotionally and mentally competent to make this appointment of a health care agent and that I understants, burdens, and risks that might result from a given treatment or course of treatment, or from the withholding or withdrawal of a treatment or course of treatment. (6) My agent shall not be liable f known to my agent. If my wishes are unknown or unclear, my agent is to make health care decisions for me in accordance with my best interest, to be determined by my agent after considering the benefith care; or ___________ When this document is signed. (5) My agent is to make health care decisions for me based on the health care instructions I give in this document and on my wishes as otherwiserity becomes operative (initial the option that applies): ___________ When my attending physician and a second physician determine that I am incapable of making an informed decision regarding my heal______________________ _____________________________________________________________________________ _____________________________________________________________________________ (4) My agent's authostances, life-sustaining procedures. -1- (3) The authority of my agent is subject to the following provisions and limitations (or write none): _______________________________________________________ facility) any hospital, hospice, nursing home, adult home, or other medical care facility; and d. Consent to the provision, withholding, or withdrawal of health care, including, in appropriate circumcal and hospital records, and consent to disclosure of this information; b. Employ and discharge my health care providers; c. Authorize my admission to or discharge from (including transfer to anothermake health care decisions for me, including the power to: a. Request, receive, and review any information, oral or written, regarding my physical or mental health, including, but not limited to, medi_________________________________ _____________________________________________________________________________ (Full Name, Address, and Telephone Number) (2) My agent has full power and authority to e Number) Optional: If this agent is unavailable or is unable or unwilling to act as my agent, then I appoint the following person to act in this capacity ____________________________________________ns for me: _____________________________________________________________________________ _____________________________________________________________________________ (Full Name, Address, and Telephon____________________________________, residing at _____________________________________________________________________________ appoint the following individual as my agent to make health care decisio cross through any items in the form that you do not want to apply. If you decide to select a health care agent that person may not be a witness to this document.) (1) I, ____________________________of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com. -6- Power of Attorney for Health Care Appointment of Health Care Agent (If you do want to appoint an agent,orney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attr any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to y person to whom the declarant has provided a copy of the directive. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability fol revocation shall document the substance of the oral revocation in the declarant's medical record. (c) It shall be the responsibility of the declarant, to the extent reasonably possible, to notify anractitioner or by the execution of a subsequent directive. (b) If a declarant revokes an advance directive by an oral statement to a health care practitioner, the practitioner and a witness to the ora treatment; § 5-604. (a) An advance directive may be revoked at any time by a declarant by a signed and dated writing, by physical cancellation or destruction, by an oral statement to a health care pification of third parties and the release of information to third parties about mental health services provided to the declarant. A statement of medications preferred by the declarant for psychiatricns for the (2) The identification of mental health professionals, programs, and facilities that the declarant would prefer to provide mental health services; (3) and (4) Instruction regarding the notvance directive for mental health services. -5- (d) An advance directive for mental health services may include: (1) declarant; The designation of an agent to make me ntal health services decisio advance directive provided under § 5-602 of this subtitle. (2) The procedures provided under § 5-604 of this subtitle for the revocation of an advance directive shall apply to the revocation of an aded for mental health services either during, or as a result of, the incompetency. (c) (1) An individual making an advance directive for mental health services shall follow the procedures for making anticle. (b) An individual who is competent may make an advance directive to outline the mental health services which may be provided to the individual if the individual becomes incompetent and has a ne presumption as to the patient's intent to consent to or refuse life-sustaining procedures. § 5-602.1. (a) In this section, "mental health services" has the meaning stated in § 4-301(i)(1) of this ar otherwise provided in the patient's advance directive, a patient's agent shall act in accordance with the provisions of § 5-605(c) of this subtitle. (i) The absence of an advance directive creates nos medical records. (g) It shall be the responsibility of the declarant to notify a health care agent that the agent has been named in an advance directive to act on the declarant's beha lf. (h) Unless (ii) If the advance directive is oral, make the substance of the advance directive, including the date the advance directive was made and the name of the attending physician, a part of the declarant' existence of the advance directive shall promptly: (i) If the advance directive is written, make the advance directive or a copy of the advance directive a part of the declarant's medical records; ores comatose, incompetent, or otherwise incapable of communication, any other person may notify the physician of the existence of an advance directive. (2) An attending physician who is notified of theer paragraph (1) of this subsection. (f) (1) It shall be the responsibility of the declarant to notify the attending physician that an advance directive has been made. In the event the declarant becomriting that the patient is incapable of making an informed decision. (2) If a patient is unconscious, or unable to communicate by any means, the certification of a second physician is not required undician and the witness. -4- (e) (1) Unless otherwise provided in the document, an advance directive shall become effective when the declarant's attending physician and a second physician certify in wphysician and one witness and if the substance of the oral advance directive is documented as part of the individual's medical record. The documentation shall be dated and signed by the attending phys to appoint an agent to make health care decisions for the individual. (2) An oral advance directive shall have the same effect as a written advance directive if made in the presence of the attending by reason of the death of the declarant. (d) (1) Any competent individual may make an oral advance directive to authorize the providing, withholding, or withdrawing of any life-sustaining procedure orrve as a witness. (iii) At least one of the witnesses must be an individual who is not knowingly entitled to any portion of the estate of the declarant or knowingly entitled to any financial benefit a witness to an advance directive, including an employee of a health care facility or physician caring for the declarant if acting in good faith. (ii) The health care agent of the declarant may not sed, signed by or at the express direction of the declarant, and subscribed by two witnesses. (2) (i) Except as provided in items (ii) and (iii) of this paragraph, any competent individual may serve as his subtitle has decision making priority over any individuals otherwise authorized under this subtitle to make health care decisions for a declarant. (c) (1) A written advance directive shall be date declarant is receiving health care may not serve as a health care agent unless the person would qualify as a surrogate decision maker under § 5-605(a) of this subtitle. (3) An agent appointed under tpointing an agent to make health care decisions for the individual under the circumstances stated in the advance directive. (2) An owner, operator, or employee of a health care facility from which therovision of health care to that individual, or the withholding or withdrawal of health care from that individual. (b) (1) Any competent individual may, at any time, make a written advance directive apd from which, despite the application of life-sustaining procedures, there can be no recovery. § 5-602. (a) Any competent individual may, at any time, make a written advance directive regarding the pt is to be rendered or withheld. (q) "Terminal condition" means an incurable condition caused by injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and, to a reasonable degree of medical certainty, that there can be no recovery. -3- (p) "Physician" means a person licensed to practice medicine in the State or in the jurisdiction where the treatmenlearned manner other than reflex activity of muscles and nerves for low level conditioned response; and (2) From which, after the passage of a medically appropriate period of time, it can be determine a condition caused by injury, disease, or illness: (1) In which a patient has suffered a loss of consciousness, exhibiting no behavioral evidence of self-awareness or awareness of surroundings in a inty, a medical procedure will not: (1) (2) (o) Prevent or reduce the deterioration of the health of an individual; or Prevent the impending death of an individual. "Persistent vegetative state" meansning procedure" includes artificially administered hydration and nutrition, and cardiopulmonary resuscitation. (n) "Medically ineffective treatment" means that, to a reasonable degree of medical certatal function; and (ii) Is of such a nature as to afford a patient no reasonable expectation of recovery from a terminal condition, persistent vegetative state, or end-stage condition. (2) "Life-sustain. (m) (1) "Life-sustaining procedure" means any medical procedure, treatment, or intervention that: (i) Utilizes mechanical or other artificial means to sustain, restore, or supplant a spontaneous viommunicate a decision. (2) For the purposes of this subtitle, a competent individual who is able to communicate by means other than speech may not be considered incapable of making an informed decisiole consequences of the proposed treatment or course of treatment, is unable to make a rational evaluation of the burdens, risks, and benefits of the treatment or course of treatment, or is unable to cke an informed decision about the provision, withholding, or withdrawal of a specific medical treatment or course of treatment because the patient is unable to understand the nature, extent, or probabents or employees of a health care practitioner or a facility that provides health care to individuals. (l) (1) "Incapable of making an informed decision" means the inability of an adult patient to maator in accordance with hospital policy. (k) (1) "Health care provider" means a health care practitione r or a facility that provides health care to individuals. (2) "Health care provider" includes agnsed or certified under the Health Occupations Article or § 13516 of the Ed ucation Article to provide health care; or -2- (2) The administrator of a hospital or a person designated by the administry; and (2) For which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective. (j) "Health care practitioner" means: (1) An individual licean advanced, progressive, irreversible condition caused by injury, disease, or illness: (1) That has caused severe and permanent deterioration indicated by incompetency and complete physical dependencompression, endotracheal intubation, other advanced airway management techniques, artificial ventilation, defibrillation, and other related life-sustaining procedures. (i) "End-stage condition" means a cardiac or respiratory arrest of a particular patient, authorizes certified or licensed emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation including cardiac citten order in a form established by protocol issued by the Maryland Institute for Emergency Medical Services in conjunction with the State Board of Physician Quality Assurance which, in the event of a competent individual who makes an advance directive while capable of making and communicating an informed decision. (h) "Emergency medical services `do not resuscitate order'" means a physician's wrder § 20-102(a) of this article has the same capacity as an adult to consent to medical treatment and who has not been determined to be incapable of making an informed decision. (g) "Declarant" means the individual receiving treatment, to the extent these may assist the decision maker in determining best interest. (f) "Competent individual" means a person who is at least 18 years of age or who uncovery, with and without the treatment; (6) The risks, side effects, and benefits of the treatment or the withholding or withdrawal of the treatment; and (7) The religious beliefs and basic values of by subjecting the individual to a condition of extreme humiliation and dependency; (4) (5) The effect of the treatment on the life expectancy of the individual; The prognosis of the individual for re (3) The degree to which the individual's medical condition, the treatment, or the withholding or withdrawal of treatment result in a severe and continuing impairment of the dignity of the individual, emotional, and cognitive functions of the individual; (2) The degree of physical pain or discomfort caused to the individual by the treatment, or the withholding or withdrawal of the treatment; -1-hat the benefits to the individual resulting from a treatment outweigh the burdens to the individual resulting from that treatment, taking into account: (1) The effect of the treatment on the physicaltle to make health care decisions for the declarant. (d) "Attending physician" means the physician who has primary responsibility for the treatment and care of the patient. (e) "Best interest" means t the declarant in accordance with the provisions of this subtitle. (c) "Agent" means an adult appointed by the declarant under an advance directive made in accordance with the provisions of this subtied. "Advance directive" means: (1) A witnessed written document, voluntarily executed by the declarant in accordance with the requirements of this subtitle; or (2) A witnessed oral statement, made by§ 5-601 et. Seq." For your convenience, we have included useful relevant excerpts from the relevant Maryland Statutes. § 5-601. (a) (b) In this subtitle the following words have the meanings indicatwitnesses may not be a person who may financially benefit by reason of your death. This Maryland Power of Attorney for Health Care is based in part on the following Maryland Statutes: "Health General ntains (1) Information and Instruction for Maryland Power of Attorney for Health Care; (2) Maryland Power of Attorney for Health Care. The health care agent may not be a witness. At least one of your ou to select and appoint a health care agent to make decisions about life-sustaining procedures in the event of terminal condition, persistent vegetative state, or end-stage condition. This package coInformation and Instructions Maryland Power of Attorney for Health Care The Maryland Power of Attorney for Health Care, allows you to make some decisions about future health care issues, by allowing y Maryland