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last revised 9/7/2004
Advance Health-Care Directive Form
18-A M.R.S.A. §§ 5-801 - 5-817
PART 1—Selection of My Agent
(Durable Power of Attorney for Health Care)
(Sections 1 through 4)
(1)DESIGNATION OF AGENT: I designate the following individual as my Agent to make health-care
decisions for me:
(name of individual you choose as Agent)
(city) (state) (zip code)
OPTIONAL: If I revoke my Agent's authority or if my Agent is not willing, able or reasonably
available to make a health-care decision for me, I designate as my first alternate Agent:
(name of individual you choose as first alternate Agent)
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