A Maine advance directive is a legal document that allows someone to choose an agent to make healthcare-related decisions for them in case they become unable to make those decisions themselves. The advance directive must be witnessed, written, and voluntarily executed by the declarant. The directive can be extremely useful in situations of sudden and serious illness or injury.
Sample
- Download: Adobe PDF
YOUR ADVANCE DIRECTIVE BEGINS HERE
Choosing an agent: Fill in your name and the name of the person you choose to be your agent to make health care decisions for you here:
My name: [NAME]
My agent’s name: [NAME]
My agent’s address: [ADDRESS, CITY, STATE, ZIP CODE]
My agent’s home phone [PHONE NUMBER]
My agent’s work phone [PHONE NUMBER]
You may change your mind later about who you want to be your agent. If you want to stop the agent you have named from making decisions for you, you must tell your primary physician or fill in these blanks: I do not want [NAME] to be my agent.
_______________________________________
My signature
[DAY] day of [MONTH], 20[XX]
Date you filled out and signed this section
Your agent’s power:
When your agent can start making decisions for you: (Check only one box: A or B)
◻ A. My agent can make decisions only when my primary physician or a judge decides that I am too sick to make my own health care decisions. OR
◻ B. My agent can start making health care decisions for me right away, but this does not mean I have given up the right to make my own decisions if I am still able and willing to make my own decisions. When my agent makes a health care decision for me, I will be told, if possible, about that decision before it is carried out unless I say I do not want to know. If I disagree with that decision and am still able to decide, I can make a different decision. As long as I am able, I can end my agent’s right to make decisions for me, change my agent or make my own decisions. If I want to end my agent’s right to make decisions for me, I must tell my primary physician or put my decision in writing and sign it with the date of my signature. Nominating a guardian: A guardian is a person chosen by a court to make decisions about your personal care. These decisions can include not only health care, but other decisions such as where you will live and how your personal needs will be met. If you wish, you may ask that a court assign your agent as your guardian, if appointment of a guardian should become necessary. Check the box below to nominate your agent to be your guardian, if a judge needs to appoint a guardian for you.
I nominate my agent to be my guardian if a judge needs to appoint a guardian for me. If you want to nominate someone other than your agent to be your guardian, you may fill in the section below. If a judge needs to appoint a guardian for me, I nominate the person named below as my guardian:
Name: [NAME]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Home Phone [PHONE NUMBER]
Work Phone [PHONE NUMBER]
If you have filled out any part of this form, you must sign and date the form on this page. You must also have two other adults sign as witnesses at the same time you sign the form. Your agent cannot sign as a witness.
Sign and date the form here:
Sign your name: _______________________
Your Address: [ADDRESS, CITY, STATE, ZIP CODE]
Print your name: ______________________
Date: [DAY] day of [MONTH], 20[XX]
First witness:
Signature: ___________________________
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Print your name: ______________________
Date: [DAY] day of [MONTH], 20[XX]
Second witness:
Signature: ___________________________
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Print your name: ______________________
Date: [DAY] day of [MONTH], 20[XX]
Adobe PDF