Health Care Power of Attorney

HEALTHCAREPOWEROFATTORNEY

UndertheUniformHealthCareDecisionsAct

18-AM.R.S.A.§5-801etseq.

I,currentlyof,,

namestreetaddresscity

Maine,whosebirthdateis ,executethisHealthCarePowerof AttorneysothatImightobtain mentalhealthcareandtreatment.

(1)DESIGNATIONOFAGENT:I,designatethefollowingindividualasmyagenttomakementalhealth-caredecisionsforme:

(nameofindividual)(homephone)(workphone)

(address)

(city)(state)(zipcode)

(2)DESIGNATIONOFALTERNATIVEAGENT:(OPTIONAL)IfIrevokethisagent’sauthorityorifmyagentisnotwilling,ableorreasonablyavailabletomakementalhealthcaredecisionsforme,Idesignateasmyfirstalternateagent:

(nameofindividual)(homephone)(workphone)

(address)

(city)(state)(zipcode)

(3)AGENTANDALTERNATIVEAGENTUNAVAILABLE: IfIrevoketheauthorityofmyagentandfirstalternateagent,ifIhavenamedone,orifneithermyagentoralternate,ifIhavenamedone,iswilling,ableorreasonablyavailabletomakehealth-caredecisionsforme,theinstructionsinthishealthcaredirectiveareneverthelesstobefollowedwithoutneedfortheexpressauthorizationofanagent. YES NO

(4)AGENT’SAUTHORITY:Myagentisauthorizedtomakeallhealth-caredecisionsthatinmyagent’sjudgmentrelatetopsychiatric,psychologicalandemotionalcareandtreatment,includingtherighttoconsent,withholdconsentorwithdrawconsenttoanytest,procedure,programofmedicationsoranyformofmentalhealthcareandtreatmentandtoselectordischargeanymentalhealthcareprovidersorinstitutions.

(5)WHENAGENT’SAUTHORITYBECOMESEFFECTIVE:Myagent’sauthoritybecomeseffectivewhen:(Indicatetheapplicableoptions)

myprimaryphysician,or,ifIshouldbeinanemergencyroomorinatreatmentsetting,theattendingphysiciandeterminesthatIamunabletomakemyownhealth-caredecisions.

myprimaryphysician,or,ifIshouldbeinanemergencyroomorinatreatmentsetting,theattendingphysiciandeterminesthatImeetinvoluntaryhospitalizationstandards.

myprimaryphysician,or,ifIshouldbeinanemergencyroomorinatreatmentsetting,theattendingphysiciandeterminesthatifIdonotreceivepsychiatrichospitalizationorthetreatmentassetoutinthisinstrumentmyconditionwillquicklydeterioratesuchthatIwouldsoonmeetthestandardforinvoluntaryhospitalization.

other. Describe

Theaboveoption(s)requireasecondphysician’sopinion.Yes.No

Iwaivethe2ndopinionrequirementifanotherphysicianisnotavailable. YesNo

(IfIrequireasecondopinionanddonotwaivetherequirementshouldnosecondphysicianbeavailable,Iunderstandthatmyadvancedirectivemaynotbecomeeffective.)

(6)AGENT’SOBLIGATION:Myagentshallmakehealth-caredecisionsformeinaccordancewiththispowerofattorneyforhealthcareandmyotherwishestotheextentknowntomyagent. Totheextentmywishesareunknown,myagentshallmakehealth-caredecisionsformeinaccordancewithwhattheagentdeterminestobeinmybestinterest. Indeterminingmybestinterest,myagentshallconsidermypersonalvaluestotheextentknowntomyagent.

(7)NOMINATIONOFGUARDIAN:(OPTIONAL)Ifaguardianofmypersonneedstobeappointedformebyacourt,Inominatethefollowingindividualtobeappointedasmyguardian.

(nameofindividual)(homephone)(workphone)

(address)

(city)(state)(zipcode)

(8)CHILDCAREARRANGEMENTS IfIamtobeadmittedtoresidentialcareortoahospital,orIamotherwiseunabletocareformychildren,andIhavenotmadepriorchildcarearrangements,Iauthorizemyagenttomakethosearrangements. Ifmyagentoralternativeisnotavailable,Irequestthatthefollowingindividualbecontactedtocareformychildrentemporarily:

(nameofindividual)(homephone)(workphone)

(address)

(city)(state)(zipcode)

(9)DESIGNATIONOFPRIMARYPHYSICIAN Idesignatethefollowingasmyprimaryphysician,forthepurposesofthisdirective:

(nameofphysician)(phonenumber)

(address)

(city)(state)(zipcode)

ACOPYOFTHISFORMHASTHESAMEEFFECTASTHEORIGINAL.

signature

Dated:

witnesssignaturewitnesssignature

witnessAddresswitnessaddress

citystatezipcodecitystatezipcode

Dated: