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HEALTHCARE POWER OF ATTORNEY
I. APPOINTMENT OF HEALTH CARE AGENT.
I, , born of , , appoint:
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
as my Agent to make health care decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.
NOTICE: An owner, operator, or employee of a health care facility from which the Declarant is receiving health care may not serve as a health care agent unless such person has a close connection with the patient.
1. Appointed as guardian for the patient;
2. The patient's spouse;
3. An adult child of the patient;
4. A parent of the patient;
5. An adult sibling of the patient; or
6. A friend or other relative who is a competent individual, and presents an affidavit to the attending physician stating specific facts and circumstances which demonstrate that the person has maintained regular contact with the patient sufficient to be familiar with the patient's activities, health and personal beliefs.
SECOND ALTERNATE AGENT:
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. STATEMENT OF AUTHORITY GRANTED. Subject to any provisions or limitations in this document, I grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, including the power to:
a. Employ and discharge my health care providers;
b. 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
c. Consent to the provision, withholding, or withdrawal of health care, including, in appropriate circumstances, life-sustaining procedures;
d. Ride with me in an ambulance if ever I need to be rushed to the hospital;
e. Be able to visit me if I am in a hospital or any other health care facility.
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 action. My agent shall not be liable for the costs of care based solely on this authorization.
. EFFECTIVE. My agent's authority becomes effective
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate my Agent (or Alternate Agent) to serve as my Guardian.
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate
| Name: |
| Address: |
| , |
to serve as my Guardian.
II. GENERAL PROVISIONS.
. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
(YOU MUST DATE AND SIGN THIS DOCUMENT
IN THE PRESENCE OF TWO WITNESSES)
By signing below, I indicate that I am emotionally and mentally competent to make this Healthcare Power of Attorney and that I understand the purpose and effect of this document. I also understand that this document replaces any similar advance directive I may have completed before this date.
Signed on _____ day of _______________, _____.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
STATEMENT OF WITNESSES
signed or acknowledged signing this Healthcare Power of Attorney in my presence and based upon my personal observation appears to be a competent individual. I am not the person appointed as the Health Care Agent or Alternate Health Care Agent by this document. I further declare that to the best of my knowledge, I am not entitled to any portion of the estate of or entitled to any financial benefit by reason of the death of .
| Witness Signature: | ________________________________________ |
Date: _________________________
| Witness Signature: | ________________________________________ |
Date: _________________________
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It is quick and easy to assign or receive the authority you need using a free Maryland Medical Power of Attorney template from Rocket Lawyer:
This method is, in most cases, notably more affordable than finding and working with a conventional law firm. If needed, you can fill out this Medical PoA on behalf of your spouse, an elderly parent, or another family member, and then have that person sign it once you've drafted it. Keep in mind that for a Power of Attorney to be considered legally valid, the principal must be an adult who is mentally competent at the time of signing. In the event that the principal is already incapacitated and unable to make their own decisions, a conservatorship may be required. When dealing with such a scenario, it is a good idea to speak to a lawyer .
Anyone who is over 18 years old should have a Medical Power of Attorney. Although it's unpleasant to acknowledge, there will likely come a day when you aren't able to make important decisions on your own. Typical occasions where power of attorney can be helpful include:
Regardless of whether your Maryland Medical Power of Attorney has been produced as a result of an unexpected emergency or as part of a forward-looking plan, notarization and/or witnesses are strongly encouraged as a best practice for protecting your agent if their privileges and authority are disputed.
Sometimes, in discussing the subjects of elder care and/or estate planning with legal or healthcare professionals, you or a loved one may find that "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" are used together. In short, they're one and the same. That said, you should keep in mind that it is certainly possible to establish agency over matters that aren't related to health care, in which case, "proxy" is not commonly used.
Maryland Medical PoA forms are normally easy to make; however, you could need advice. Finding a legal professional to provide feedback on your document might take a lot of time if you attempt to do it by yourself. Another approach worth consideration is to get help via the Rocket Lawyer On Call® network of attorneys. Premium members have the ability to request a document review from an experienced lawyer or get answers to other questions. As always, you can live confidently with Rocket Lawyer by your side.
The cost of finding and hiring a lawyer to draft a Medical Power of Attorney can total anywhere between $200 and $500. Unlike many other sites that you might stumble upon, Rocket Lawyer offers more than a Power of Attorney template. If you ever require help from a lawyer, your membership provides up to a 40% discount when you hire an attorney.
With a Premium membership, you will be able to edit it, save it as a PDF document or Word file, and/or print it. When you are ready to wrap up your Power of Attorney, it should be signed. You will need to send a final copy of your signed document to your agent(s) and care providers.
The guidelines and restrictions for PoA forms are different in each state; however, in Maryland, your Power of Attorney will require the signatures of two witnesses. At least one of the witnesses should be someone who is not your heir or beneficiary. As a basic rule, witnesses will need to be over 18 years old, and none of them should simultaneously be named as your agent.
See Maryland Medical/Healthcare Power of Attorney law: Health - General, Section 5
