Maine Medical Power of Attorney
This Maine Medical Power of Attorney allows you to appoint someone to make healthcare decisions on your behalf if you are unable to do so. This document is governed by the Maine Revised Statutes Title 18-C, § 5-801 to § 5-810.
Principal Information:
- Name: _____________________________
- Address: ___________________________
- City, State, Zip: _________________
- Date of Birth: _____________________
Agent Information:
- Name: _____________________________
- Address: ___________________________
- City, State, Zip: _________________
- Phone Number: ______________________
You grant this authority willingly, providing the agent the power to make decisions regarding your medical treatment. This power will take effect upon your incapacitation as determined by a physician.
Agent's Authority Includes:
- Consent to or refuse medical treatment.
- Make decisions about medical procedures.
- Access medical records and information.
- Decide about end-of-life care.
Limitation of Authority:
Your agent is not authorized to make decisions on matters of health care that are contrary to your known wishes. This includes any instructions given during your lifetime.
Signature:
Signed this _____ day of __________, 20____.
Principal's Signature:_________________________
Witness 1 Signature:_________________________
Witness 2 Signature:_________________________
Notarization:
State of Maine
County of _______________
Subscribed and sworn before me this _____ day of __________, 20____.
Notary Public: ___________________________