Maine Medical Power of Attorney Template
This Medical Power of Attorney is executed under the laws of the State of Maine. It allows you to designate an individual to make healthcare decisions on your behalf if you become unable to do so.
Principal Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: _____________________
- Date of Birth: ________________________
Agent Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: _____________________
- Phone Number: ________________________
Effective Date:
This Medical Power of Attorney becomes effective when I am unable to make my own healthcare decisions.
Authority Granted:
I grant my Agent the authority to make decisions regarding my medical treatment, including but not limited to:
- Consent to or refuse medical treatment.
- Access my medical records.
- Make decisions regarding life-sustaining treatment.
Limitations:
The authority granted to my Agent is subject to the following limitations:
- _________________________________________________________________
- _________________________________________________________________
Revocation:
This Medical Power of Attorney can be revoked at any time by notifying my Agent in writing.
Signatures:
By signing below, I affirm that I am of sound mind and that I am executing this document voluntarily.
_______________________________
Signature of Principal
_______________________________
Date
Witnesses:
This document must be witnessed by two individuals who are not related to the Principal or the Agent.
_______________________________
Signature of Witness 1
_______________________________
Date
_______________________________
Signature of Witness 2
_______________________________
Date
Notary Public:
State of Maine, County of ________________
Subscribed and sworn to before me this _____ day of ______________, 20__.
_______________________________
Notary Public
My commission expires: _______________