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ADVANCE DIRECTIVE
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. TREATMENT PREFERENCES ("LIVING WILL"). (Initial all that 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.
. TERMINAL CONDITION
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:
. PERSISTENT VEGETATIVE STATE
If my doctors certify that I am in a persistent vegetative state, that is, if I am not conscious and am not aware of myself or my environment or able to interact with others, and there is no reasonable expectation that I will ever regain consciousness:
. END-STAGE CONDITION
If my doctors certify that I am in an end-state condition, that is, an incurable condition that will continue in its course until death and that has already resulted in loss of capacity and complete physical dependency:
______
______ If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
. EFFECT OF STATEMENT OF PREFERENCES
III. 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 Advance Directive 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 Advance Directive 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: _________________________
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
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It's very easy to document your medical wishes with a free Maryland Living Will template from Rocket Lawyer:
This solution is, in most cases, much less expensive and less time-consuming than finding and working with a traditional attorney. If necessary, you may prepare a Living Will on behalf of a family member, and then have them sign once you've drafted it. Keep in mind that for a Living Will 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 has already been declared legally incompetent, a court-appointed conservatorship might be required. When dealing with this scenario, it is important to talk to an attorney .
Everyone over 18 years old ought to have a Living Will. Although it's painful to think about, a day will likely come when you can no longer make important decisions on your own. Here are a few typical occasions in which it might be useful to make or update your Living Will:
Whether this Maryland Living Will is being created in response to a recent change in your health or as part of a long-term plan, witnesses and/or notarization can often help to protect your agent if their authority is disputed.
Making a Living Will is typically simple to do, but you could need legal advice. It will vary depending on whom you approach, but quite often, some attorneys may not even agree to review a document if they were not the author. An easier approach would be through Rocket Lawyer attorney services. By signing up for a Premium membership, you will be able to request feedback from an experienced attorney or send other questions about your Living Will. We are always here to support you.
The cost of hiring a traditional legal provider to make a Living Will could add up to anywhere between $200 and $1,000. Rocket Lawyer offers much more than most other Living Will template websites that you might find. As a Rocket Lawyer Premium member, you can get up to 40% in savings when hiring an attorney.
With a Premium membership, you may edit it, download it, and/or print it out. In order to make your Maryland Living Will truly legal, you must sign it. Be sure to give a final copy of your signed document to your agent(s), care providers, and other impacted parties.
The specific requirements are different in each state; however, in Maryland, your document requires the signatures of two witnesses. At least one of the witnesses should be someone who is not your heir or beneficiary. As a general principle, witnesses will need to be over the age of 18, and none of them should also be your healthcare agent.
