 | Maine Medical Power of Attorney Form |
The Maine medical power of attorney form is a document that is utilized by a Principal for the purpose of selecting an Agent to the Principal will be able to acquire the health care treatment that they have discussed with their Agent(s) whom they trust to properly guide health care providers.
These instructions will be in place so that in the event that the Principal should become incapacitated, there will immediately be someone available to make decisions on behalf of the Principal. This document is also designed to provide instructions, even if there is no Agent available, for the health care providers to carefully allow the document to guide them without authorization of an Agent. This is an option and does not have to be selected if the Principal would prefer to have an Agent make authorization.
This document may be revoked, by the Principal at any time. This document will require the signatures of two (2) witnesses.
How to Write
Step 1 – Parties Information – Enter the following:
- Principal’s name
- Current street address
- City
- Date of Birth in mm/dd/yyyy format
- AND
- Provide the name of the selected Agent
- Agent’s address
- City, State, Zip Code
- Home Phone
- Work Phone
- AND
- Designate an Alternate Agent by entering the name of the Alternate
- Street Address
- City, State, Zip Code
- Home Phone
- Work Phone
Step 2 – Health Care Powers –
- Enter the name of the Principal
Step 3 – Agent and Alternative Agent are Unavailable
- Read the information under this title and check, appropriately, yes or no
Step 4 – Agent’s Authority –
- Agent’s must review the information under this title
Step 5 – When Agent’s Authority Becomes Effective –
- The Principal may check any or all of the boxes that would indicate their preference with regard to when the document would become effective
- Review the section under this title and make the appropriate selections
- If the Principal would like to require a physician’s second opinion, check the appropriate box
- If there is no other physician available for a second opinion, check the applicable box according to the Principal’s preference (answering “yes” to this section may disallow the Advanced Directive from going into effect)
Step 5 – Agent’s Obligation –
- Both Agent’s must read this title
Step 6 – Nomination of Guardian (Optional) – Read this title and enter the following, if interested:
- Guardian’s Name
- Current Address
- City, State, Zip Code
- Home Phone
- Work Phone
Step 7 – Child Care Arrangements – If the Principal has children and this section applies, complete the following:
- Child Care Provider’s Name
- Address
- City, State, Zip Code
- Home Phone
- Work Phone
Step 8 – Designation of Primary Care Physician –
- Physician’s Name
- Address
- City, State, Zip Code
- Phone Number
Step 9 – Signatures –
- Enter the Principal’s Signature
- Enter the date of the signature in mm/dd/yyyy format
Witnesses Information –
- Respective signatures of both witnesses
- Witnesses Addresses
- City, State, Zip Codes
- Each witness must enter the date of their entry of information in mm/dd/yyyy format
