Fill and Sign the Advance Directives Maryland Attorney General Form

Maryland Advance Directive: Planning for Future Health Care Decisions By: _____________________________________ (Print Name) Date of Birth: ______________________ (Month/Day/Year) Using this advance directive form to do health care planning is completely optional. Other forms are also valid in Maryland. No matter what form you use, talk to your family and others close to you about your wishes. This form has two parts to state your wishes, and a third part for needed signatures. Part I of this form lets you answer this question: If you cannot (or do not want to) make your own health care decisions, who do you want to make them for you? The person you pick is called your health care agent. Make sure you talk to your health care agent (and any back-up agents) about this important role. Part II lets you write your preferences about efforts to extend your life in three situations: terminal condition, persistent vegetative state, and end-stage condition. In addition to your health care planning decisions, you can choose to become an organ donor after your death by filling out the form for that too. You can fill out Parts I and II of this form, or only Part I, or only Part II. Use the form to reflect your wishes, then sign in front of two witnesses (Part III). If your wishes change, make a new advance directive. Make sure you give a copy of the completed form to your health care agent, your doctor, and others who might need it. Keep a copy at home in a place where someone can get it if needed. Review what you have written periodically. PART I: SELECTION OF HEALTH CARE AGENT A. Selection of Primary Agent I select the following individual as my agent to make health care decisions for me: Name: _____________________________________
Address: place of birth: age: occupation: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Print name: address: place of birth: age: occupation: please provide your preferred agents address as listed above. It is better if you can give both: the address of your health care agent, and a phone number. Fill out and sign the form part one. Part ii. Preferences and directives: selection of health care agent a. Preferences and directives: end of life directives the following can be listed as preferences and/or directives for the use at end of life: 1. Health care agent with terminal illness: 2. Health care agent with persistent vegetative state: 3. Health care agent with end-stage condition: 4. Health care agent who wants me to make health care decisions for him/her alone or has no agent: 5. No health care agent or other person to make decisions for me: 6. No specific living standard to be expected from myself at any time: 7. No specific level of income or resources to be expected from myself at any time: 8. No specific level of income or resources to be expected from a family member at any time: (this section also applies to individuals to whom the “health care agent with terminal illness" section applies) print name: address: place of birth: age: occupation: print name: address: place of birth: age: occupation: