Fillable Maryland Living Will Template

Maryland Living Will

This Living Will is designed to reflect the wishes of ________ [Your Full Name], herein referred to as the "Principal", concerning medical treatment preferences in the event of a severe health condition that leaves the Principal unable to communicate their desires directly. This document is made according to the Maryland Health Care Decisions Act.

Principal Information:

• Full Name: ___________________________
• Address: _____________________________
• City: _______________ State: Maryland
• Zip Code: ____________
• Date of Birth: ___________

Appointment of Health Care Agent:

I hereby appoint the following person as my Health Care Agent to make medical decisions on my behalf should I become unable to communicate my wishes:

• Agent's Full Name: _____________________________
• Relationship to Principal: ______________________
• Address: ______________________________________
• Phone Number: _________________________________

Should my primary agent be unable, unwilling, or unavailable to serve, I appoint the following person as my alternate Health Care Agent:

• Alternate Agent's Full Name: ________________________
• Relationship to Principal: ___________________________
• Address: __________________________________________
• Phone Number: _____________________________________

Health Care Instructions:

It is my wish that if I am in a state of terminal illness, persistent vegetative state, or end-stage condition where the application of life-sustaining procedures would serve only to artificially prolong the process of my dying, the following should be adhered to:

1. I do / do not (circle one) want my life to be prolonged by life-sustaining treatments. If I have marked "do not", let me die naturally and provide only treatment that is necessary for my comfort and to relieve pain.
2. I do / do not (circle one) wish to receive nutrition and hydration provided by medical means if I am unable to take food or water by mouth.

Signature and Acknowledgment:

This Living Will shall be effective upon my signature and remains effective indefinitely unless I revoke it.

_________________________________
Principal's Signature

_________________
Date

This document was signed in the presence of two witnesses, who are not related to me, not beneficiaries of my estate, and have no claim to my estate. The witnesses are not my attending physician or employees of my attending physician or health care facility in which I am a patient.

Witness 1 Signature: ___________________________ Date: ____________

Witness 1 Printed Name: _______________________

Witness 2 Signature: ___________________________ Date: ____________

Witness 2 Printed Name: _______________________

Notarization (Optional):

This section to be completed by a Notary Public if the Principal opts for notarization of this document.

Subscribed and sworn to before me by the Principal, __________ [Your Full Name], this ___ day of _________, 20__.

Notary Public: ____________________________

Commission Expires: _______________________