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Maryland Advance Directive Form

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.

Signing Requirements (MD Code, Health – General, § 5-602) – Two (2) witnesses. At least one of the witnesses must not be knowingly entitled to any portion of the declarant’s estate.

Statutory Form

Planning for Future Health Care Decisions

By:

[NAME]
(Print Name)

PART I : SELECTION OF HEALTH CARE AGENT

A. Selection of Primary 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)

B. Selection of Back-up Agents (Optional; form valid if left blank)

1. If my primary agent cannot be contacted in time or for any reason is unavailable or unable or unwilling to act as my agent, then I select the following person to act in this capacity:

Name: [NAME]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Telephone Numbers: [HOME PHONE NUMBER] [CELL PHONE NUMBER](home and cell)

2. If my primary agent and my first back-up agent cannot be contacted in time or for any reason are unavailable or unable or unwilling to act as my agent, then I select the following person to act in this capacity:

Name: [NAME]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Telephone Numbers: [HOME PHONE NUMBER] [CELL PHONE NUMBER](home and cell)

C. Powers and Rights of Health Care Agent

I want my agent to have full power to make health care decisions for me, including the power to:

1. Consent or not consent to medical procedures and treatments which my doctors offer, including things that are intended to keep me alive, like ventilators and feeding tubes;
2. Decide who my doctor and other health care providers should be; and
3. Decide where I should be treated, including whether I should be in a hospital, nursing home, other medical care facility, or hospice program.

I also want my agent to:

1. Ride with me in an ambulance if ever I need to be rushed to the hospital; and
2. Be able to visit me if I am in a hospital or any other health care facility.
This advance directive does not make my agent responsible for any of the costs of my care.

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.

G. Access to My Health Information – Federal Privacy Law (HIPAA)Authorization
1. If, prior to the time the person selected as my agent has power to act under this document, my doctor wants to discuss with that person my capacity to make my own health care decisions, I authorize my doctor to disclose protected health information which relates to that issue.
2. Once my agent has full power to act under this document, my agent may request, receive, and review any information, oral or written, regarding my physical or mental health, including, but not limited to, medical and hospital records and other protected health information, and consent to disclosure of this information.
3. For all purposes related to this document, my agent is my personal representative under the Health Insurance Portability and Accountability Act (HIPAA). My agent may sign, as my personal representative, any release forms or other HIPAA-related materials.
H. Effectiveness of This Part(Read both of these statements carefully. Then, initial one only.)
My agent’s power is in effect:
1. Immediately after I sign this document, subject to my right to make any decision about my health care if I want and am able to. [INITIALS]
2. Whenever I am not able to make informed decisions about my health care, either because the doctor in charge of my care (attending physician) decides that I have lost this ability temporarily, or my attending physician and a consulting doctor agree that I have lost this ability permanently. [INITIALS]

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)