Maryland Medical Power of Attorney Template
This document allows you to appoint someone to make medical decisions on your behalf in the event that you are unable to do so. This Medical Power of Attorney is governed by Maryland state laws.
Principal Information:
- Name: ___________________________
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- City, State, Zip Code: ___________________________
- Date of Birth: ___________________________
Agent Information:
- Name: ___________________________
- Address: ___________________________
- City, State, Zip Code: ___________________________
- Phone Number: ___________________________
Effective Date:
This Medical Power of Attorney will become effective when I am unable to make my own medical decisions.
Agent's Authority:
The agent has the authority to make decisions regarding my medical care, including but not limited to:
- Choosing healthcare providers.
- Consenting to or refusing treatment.
- Accessing my medical records.
Limitations:
The agent shall not have the authority to:
- Make decisions regarding organ donation.
- Make decisions regarding the withholding or withdrawal of life-sustaining treatment unless specified below.
Specific Instructions:
____________________________________________________________________
____________________________________________________________________
Signature:
I, ___________________________ (Principal's Name), sign this Medical Power of Attorney on this _____ day of __________, 20__.
Signature: ___________________________
Witnesses:
This document must be witnessed by two individuals who are not related to the Principal or the Agent.
- Witness 1 Name: ___________________________
- Witness 1 Signature: ___________________________
- Witness 2 Name: ___________________________
- Witness 2 Signature: ___________________________
Notary Public:
State of Maryland
County of _______________
Subscribed and sworn before me on this _____ day of __________, 20__.
Notary Public Signature: ___________________________
My Commission Expires: ___________________________