Health Care Power of Attorney - Maine

HEALTH CARE POWER OF ATTORNEY of _______________________ Page ___2___
(3) AGENT AND ALTERNATIVE AGENT UNAVAILABLE: If I revoke the authority of
my agent and first alternate agent, if I have named one, or if neither my agent or alternate, if I
have named one, is willing, able or reasonably available to make health-care decisions for me,
the instructions in this health care directive are nevertheless to be followed without need for the
express authorization of an agent. YES____ NO_____
(4) AGENT’S AUTHORITY: My agent is authorized to make all health-care
decisions that in my agent’s judgment relate to psychiatric, psychological and emotional care and
treatment, including the right to consent, withhold consent or withdraw consent to any test,
procedure, program of medications or any form of mental health care and treatment and to select
or discharge any mental health care providers or institutions.
(5) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority
becomes effective when: (Indicate the applicable options)
____ my primary physician, or, if I should be in an emergency room or in a treatment setting,
the attending physician determines that I am unable to make my own health-care decisions.
_____ my primary physician, or, if I should be in an emergency room or in a treatment setting,
the attending physician determines that I meet involuntary hospitalization standards.
_____ my primary physician, or, if I should be in an emergency room or in a treatment setting,
the attending physician determines that if I do not receive psychiatric hospitalization or the
treatment as set out in this instrument my condition will quickly deteriorate such that I would
soon meet the standard for involuntary hospitalization.
______ other. Describe ____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The above option(s) require a second physician’s opinion. Yes._____ No _____
I waive the 2
nd
opinion requirement if another physician is not available. Yes _____ No ______
(If I require a second opinion and do not waive the requirement should no second physician be
available, I understand that my advance directive may not become effective.)
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