Maine Medical Power of Attorney
This Medical Power of Attorney is established in accordance with the Maine Health Care Advance Directive Act. It is a legal document that allows you, the Principal, to designate a trusted person, known as the Agent, to make health care decisions on your behalf if you become unable to make them yourself.
Please fill in the blanks with the required information to personalize your document.
Principal Information
Full Name: _____________
Address: _____________
City: ________________
State: Maine
Zip Code: _____________
Date of Birth: _____________
Phone Number: _____________
Agent Information
Full Name: _____________
Relationship to Principal: _____________
Address: _____________
City: ________________
State: _______________
Zip Code: _____________
Phone Number: _____________
Alternative Phone Number: _____________
Alternate Agent Information (Optional)
If the primary Agent is unable or unwilling to serve, an alternate Agent can act on the Principal's behalf.
Full Name: _____________
Relationship to Principal: _____________
Address: _____________
City: ________________
State: _______________
Zip Code: _____________
Phone Number: _____________
Alternative Phone Number: _____________
Authority of the Agent
The Agent is authorized to make all forms of health care decisions on the Principal's behalf that the Principal could make, including decisions about refusing or consenting to treatment, hiring health care personnel, and deciding on living arrangements related to health care. This authority becomes effective only when the Principal is deemed unable to make their own health care decisions.
Special Instructions
The Principal may state any specific wishes or limitations concerning health care decisions:
_____________________________________________________
_____________________________________________________
Signature
This document must be signed and dated by the Principal, in the presence of two witnesses who also need to sign and date the document. Witnesses must not be the Principal's health care provider, an employee of the health care provider, the named agent, or related to the Principal by blood, marriage, or adoption.
Principal's Signature: _____________ Date: _____________
Witness 1 Signature: _____________ Date: _____________
Witness 1 Printed Name: _____________
Witness 2 Signature: _____________ Date: _____________
Witness 2 Printed Name: _____________
Notarization (Optional)
If notarization is desired or if required by third-party entities, a notary public must witness the Principal signing the document.
Notary Public Signature: _____________ Date: _____________
Notary Public Printed Name: _____________
My commission expires: _______________
This document does not authorize the Agent to make financial decisions on the Principal's behalf. For financial matters, a separate Power of Attorney document is required.