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About this form: The Maryland Advance Health Care Directive with Health Care Instructions fulfills the same function as a durable power of attorney for health care. The person signing this document (the principal) may designate as his or her health care agent anyone who is 18 or older except, in general, an owner, operator, or employee of a health care facility where the principal is receiving care. Two witnesses are needed at the time this legal form is signed. Generally, any competent adult can serve as a witness, including a doctor or other health care provider (but be aware that some facilities have a policy against their employees serving as witnesses). If the principal names a health care agent, that person cannot be a witness for any of the principal's advance directives. Also, one of the two witnesses must be someone who (i) will not receive money or property from the principal's estate and (ii) who is not the one the principal has named to handle the estate after the principal's death. This form does not need to be notarized, but if the principal travels frequently to another state, check to see if that state requires notarization.
 


 

MARYLAND ADVANCE HEALTH CARE DIRECTIVE

 

PART A

APPOINTMENT OF HEALTH CARE AGENT

 

(Cross through this whole part of the form if you do not want to appoint a health care agent to make health care decisions for you.  If you do want to appoint an agent, cross through any items in the form that you do not want to apply.)

 

1.             I, _____________________________________________________________________,
residing at ______________________________________________________________
_______________________________________________________________________
appoint the following individual as my agent to make health care decisions for me:

_______________________________________________________________________

_______________________________________________________________________

(Full Name, Address, and Telephone Number of Agent)

 

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:

_______________________________________________________________________

_______________________________________________________________________

(Full Name, Address, and Telephone Number of Back-up Agent)

 

2.             In accordance with the Health Insurance Portability and Accountability Act (“HIPAA”), a health care agent is a personal representative and is entitled to request and receive protected health information.

 

3.             My agent has full power and authority to make health care decisions for me, including the power to:

 

A.      In accordance with HIPAA and as my personal representative, request, receive, and review any information, oral or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, and other protected health information, 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 another 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 circumstances, life sustaining procedures.

 

4.             The authority of my agent is subject to the following provisions and limitations:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

5.             If I am pregnant, my agent shall follow these specific instructions:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

6.             My agent's authority becomes operative (initial only the one option that applies):

 

_______      When my attending physician and a second physician determine that I am incapable of making an informed decision regarding my health care; provided however, when this document is signed, each individual identified in paragraph (1) is, in accordance with HIPAA, my personal representative for all purposes related to any assessment of my capacity to make an informed decision regarding my health care; or

 

_______      When this document is signed.

 

7.             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 otherwise 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 benefits, 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.

 

8.             My agent shall not be liable for 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 understand its purpose and effect.

 

 

__________________     _____________________________________________

(Date)                            (Signature of Declarant)

 

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 competent individual.

 

 

________________________________                      ________________________________

(Witness)                                                                (Witness)

________________________________                      ________________________________

________________________________                      ________________________________

________________________________                      ________________________________

 

(Signatures and Addresses of Two Witnesses)


 

PART B

HEALTH CARE INSTRUCTIONS

 

(Cross through this whole part of the form if you do not want to use it to give health care instructions. If you do want to complete this portion of the form, initial those statements you want to be included in the document and cross through those statements that do not apply.)

 

If I am incapable of making an informed decision regarding my health care, I direct my health care providers to follow my instructions as set forth below.  (Initial all those that apply.)

 

1.             If my death from a terminal condition is imminent and even if life-sustaining procedures are used there is no reasonable expectation of my recovery:

 

_______      I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.

 

_______      I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially.

 

2.             If I am in a persistent vegetative state, that is, if I am not conscious and am not aware of my environment nor able to interact with others, and there is no reasonable expectation of my recovery:

 

_______      I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.

 

_______      I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially.

 

3.             If I have an end-stage condition, that is, a condition caused by injury, disease, or illness, as a result of which I have suffered severe and permanent deterioration indicated by incompetency and complete physical dependency and for which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective:

 

_______      I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.

 

_______      I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take food and water by mouth, I wish to receive nutrition and hydration artificially.

 

4.             _______      I direct that, no matter what my condition, medication to relieve pain and suffering not be given to me if the medication would shorten my remaining life.

 

5.             _______      I direct that, no matter what my condition, I be given all available medical treatment in accordance with accepted health care standards.

 

6.             If I am pregnant, my decision concerning life-sustaining procedures shall be modified as follows:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

7.             I direct (in the following space, indicate any other instructions regarding receipt or nonreceipt of any health care):

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

By signing below, I indicate that I am emotionally and mentally competent to make this Advance Directive and that I understand the purpose and effect of this document.

 

 

__________________     _____________________________________________

(Date)                            (Signature of Declarant)

 

The declarant signed or acknowledged signing these health care instructions in my presence and, based upon my personal observation, appears to be a competent individual.

 

 

________________________________                      ________________________________

(Witness)                                                                (Witness)

________________________________                      ________________________________

________________________________                      ________________________________

________________________________                      ________________________________

 

(Signatures and Addresses of Two Witnesses)


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