Power of Attorney for Health Care Will to Live Form - Maine

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Maine Power of Attorney for Health Care
Will to Live Form
I, (your name)__________________________________________________________________
(your address)__________________________________________________________________
_____________________________________________________________________________
(your phone number)____________________________________________________________
designate:
(Name of agent)________________________________________________________________
(address of agent)_______________________________________________________________
(phone number(s) of agent)________________________________________________________
as my health care agent to make any health care decisions for me as authorized in this document
consistent with the instructions below.
If the person I appoint above refuses or is not able to act for me, I appoint the following persons
(each to act alone and successively, in the order named):
A. First Successor Agent
(successor agent’s name)_________________________________________________________
(successor agent’s address)________________________________________________________
_____________________________________________________________________________
(successor agent’s phone number)__________________________________________________
B. Second Successor Agent
(second successor agent’s name)___________________________________________________
(second successor agent’s address)__________________________________________________
______________________________________________________________________________
(second successor agent’s phone number)____________________________________________
as my health care agent to make any health care decisions for me as authorized in this document
consistent with the instructions below.
This designation shall become effective when it is communicated to my attending physician and
it is determined by my attending physician that I am no longer able to make or communicate
decisions regarding administration of life-sustaining treatment and that I have an incurable and
irreversible condition that without the administration of life-sustaining treatment will, in the
opinion of my attending physician, result in my death within a relatively short time.
Any prior designation is revoked.
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Power of Attorney for Health Care Will to Live Form - Maine PDF

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