Maine Medical Power of Attorney
This Medical Power of Attorney is established in accordance with the laws of the State of Maine.
I, [Your Name], residing at [Your Address], born on [Your Date of Birth], hereby designate the following individual as my Health Care Agent:
[Agent's Name]
Address: [Agent's Address]
Phone: [Agent's Phone Number]
Relationship: [Agent's Relationship to You]
If the above-named agent is unavailable or unwilling to serve, I designate the following individual as my alternate Health Care Agent:
[Alternate Agent's Name]
Address: [Alternate Agent's Address]
Phone: [Alternate Agent's Phone Number]
Relationship: [Alternate Agent's Relationship to You]
I give my Health Care Agent the authority to make health care decisions on my behalf. These decisions may include:
- Choosing health care providers.
- Consent for or refusal of medical treatments.
- Accessing my medical records.
- Making decisions about life-sustaining treatments.
This Medical Power of Attorney is effective in the event that I am unable to make my own health care decisions due to:
- Illness.
- Injury.
- Any other condition that affects my ability to communicate.
My agent’s authority starts when my attending physician determines that I am unable to make my own health care decisions.
I understand that I can revoke this Medical Power of Attorney at any time as long as I am competent to do so. Revocation can be made verbally or in writing.
Sign this document to indicate your acceptance of this designation:
______________________________
Signature of Principal (You)
Date: _________________________
Witnesses:
Witness 1: _______________________________
Witness 2: _______________________________
Both witnesses must be at least 18 years old and cannot be your appointed agent.