A Maryland advance directive is a form that a resident of Maryland can use to designate someone else to make their healthcare-related decisions. The directive can also be used to outline preferences for treatments that might be used to sustain life. This can be extremely beneficial in case of emergencies, including sudden mental incapacitation.
Statutory Form
- Statute: Md. Code, Health-Gen. § 5-603
- Download: Adobe PDF
Planning for Future Health Care Decisions
By:
[NAME]
(Print Name)
PART I : SELECTION OF HEALTH CARE AGENT
I select the following individual as my agent to make health care decisions for me:
Name: [NAME] Address: [ADDRESS, CITY, STATE, ZIP CODE] Telephone Numbers: [HOME PHONE NUMBER] [CELL PHONE NUMBER](home and cell)
Name: [NAME]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Telephone Numbers: [HOME PHONE NUMBER] [CELL PHONE NUMBER](home and cell)
Name: [NAME]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Telephone Numbers: [HOME PHONE NUMBER] [CELL PHONE NUMBER](home and cell)
I want my agent to have full power to make health care decisions for me, including the power to:
I also want my agent to:
D. How My Agent Is to Decide Specific Issues
I trust my agent’s judgment. My agent should look first to see if there is anything in Part II of this advance directive that helps decide the issue. Then, my agent should think about the conversations we have had, my religious or other beliefs and values, my personality, and how I handled medical and other important issues in the past. If what I would decide is still unclear, then my agent is to make decisions for me that my agent believes are in my best interest. In doing so, my agent should consider the benefits, burdens, and risks of the choices presented by my doctors.
My agent’s power is in effect:
SIGNATURE AND WITNESSES
By signing below as the Declarant, I indicate that I am emotionally and mentally competent to make this advance directive and that I understand its purpose and effect. I also understand that this document replaces any similar advance directive I may have completed before this date.
____________________________________________
(Signature of Declarant)
[DAY] day of [MONTH], 20[XX]
(Date)
The Declarant signed or acknowledged signing this document in my presence and, based upon personal observation, appears to be emotionally and mentally competent to make this advance directive.
____________________________________________
(Signature of Witness)
[DAY] day of [MONTH], 20[XX]
(Date)
____________________________________________
(Signature of Witness)
[DAY] day of [MONTH], 20[XX]
(Date)