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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__________________________, ______________________,
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
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