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Maine Health Care Power of Attorney Form 1


Maine Health Care Power of Attorney Form 1
HEALTH CARE POWER OF ATTORNEY
Under the Uniform Health Care Decisions Act
18-A M.R.S.A. § 5-801 et seq.
I, ________________ currently of__________________________, ______________________,
name
street address city
Maine, whose birth date is ________________, execute this Health Care Power of Attorney so
that I might obtain mental health care and treatment.
(1) DESIGNATION OF AGENT: I, designate the following individual as my agent
to make mental health-care decisions for me:
__________________________________________ ______________________________
(name of individual) (home phone) (work phone)
________________________________________________________
(address)
________________________________________________________
(city) (state) (zip code)
(2) DESIGNATION OF ALTERNATIVE AGENT: (OPTIONAL) If I revoke this
agent’s authority or if my agent is not willing, able or reasonably available to make mental health
care decisions for me, I designate as my first alternate agent:
__________________________________________ ______________________________
(
name of individual) (home phone) (work phone)
________________________________________________________
(address)
________________________________________________________
(city) (state) (zip code)
Maine Health Care Power of Attorney Form 1
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