Health Care Power of Attorney - Maine

HEALTH CARE POWER OF ATTORNEY of __________________________ Page__3__
(6) AGENT’S OBLIGATION: My agent shall make health-care decisions for me in
accordance with this power of attorney for health care and my other wishes to the extent known
to my agent. To the extent my wishes are unknown, my agent shall make health-care decisions
for me in accordance with what the agent determines to be in my best interest. In determining
my best interest, my agent shall consider my personal values to the extent known to my agent.
(7) NOMINATION OF GUARDIAN: (OPTIONAL) If a guardian of my person needs to be
appointed for me by a court, I nominate the following individual to be appointed as my guardian.
__________________________________________ ______________________________
(name of individual) (home phone) (work phone)
________________________________________________________
(address)
________________________________________________________
(city) (state) (zip code)
(8) CHILD CARE ARRANGEMENTS If I am to be admitted to residential care or
to a hospital, or I am otherwise unable to care for my children, and I have not made prior child
care arrangements, I authorize my agent to make those arrangements. If my agent or alternative
is not available, I request that the following individual be contacted to care for my children
temporarily:
__________________________________________ ______________________________
(name of individual) (home phone) (work phone)
________________________________________________________
(address)
________________________________________________________
(city) (state) (zip code)
(9) DESIGNATION OF PRIMARY PHYSICIAN I designate the following as my
primary physician, for the purposes of this directive:
______________________________________________ _______________________
(
name of physician) (phone number)
______________________________________________
(address)
_______________________________________________________________
(city) (state) (zip code)
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Health Care Power of Attorney - Maine PDF

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