Maryland Medical Power of Attorney
This Medical Power of Attorney is a legal document that authorizes an individual (referred to as the "Agent") to make healthcare decisions on behalf of the person creating the document (referred to as the "Principal"), according to the Maryland Health Care Decisions Act. This document comes into effect when the Principal is unable to make their own decisions regarding medical treatment.
Please fill in the following details to complete your Maryland Medical Power of Attorney:
Principal's Information:
- Full Name: ___________________________
- Date of Birth: _______________________
- Address: _____________________________
Agent's Information:
- Full Name: ___________________________
- Relationship to Principal: ____________
- Primary Phone Number: _________________
- Alternate Phone Number: _______________
Alternate Agent's Information (Optional):
- Full Name: ___________________________
- Relationship to Principal: ____________
- Primary Phone Number: _________________
- Alternate Phone Number: _______________
In the event that the Agent is unable, unwilling, or unavailable to perform his or her duties, the Alternate Agent will assume these responsibilities.
Special Instructions:
Here, you might include any specific wishes, limitations, or special instructions you want to apply to your health care decisions:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Signatures:
This document must be signed by the Principal, the Agent, and the Alternate Agent (if applicable) in the presence of a Notary Public to be legally binding.
Principal's Signature: _____________________ Date: ___________
Agent's Signature: ________________________ Date: ___________
Alternate Agent's Signature: _______________ Date: ___________ (Optional)
Notary Acknowledgement
This section will be completed by a Notary Public, confirming the identities of the signatories and the voluntary nature of their signatures.
State of Maryland )
County of ___________ )
On this ___ day of ___________, 20__, before me, a Notary Public, personally appeared ______________________ (Principal), ______________________ (Agent), and ______________________ (Alternate Agent, if any), known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
Notary Public's Signature: ____________________
My commission expires: _______________________