Fillable Maryland Medical Power of Attorney Template

The Maryland Medical Power of Attorney is a legal document that allows an individual (the Principal) to appoint someone they trust (the Agent) to make healthcare decisions on their behalf in case they become unable to do so. This document complies with the Maryland Health Care Decisions Act.

Principal Information:

• Full Name: ___________________________
• Address: _____________________________
• City, State, Zip: ________________________
• Date of Birth: _________________________
• Phone Number: ________________________

Agent Information:

• Full Name: ___________________________
• Address: _____________________________
• City, State, Zip: ________________________
• Phone Number: ________________________
• Alternate Phone Number: _______________

This Medical Power of Attorney becomes effective upon the incapacity of the Principal, as determined by a physician, to make healthcare decisions.

Powers Granted to the Agent:

1. To consent, refuse, or withdraw consent to any type of medical care, treatment, service, or procedure.
2. To have access to the Principal's medical records necessary for making informed decisions about the Principal's healthcare.
3. To make decisions about the Principal's admission to or discharge from medical facilities.
4. To request, receive, and review any information relating to the Principal's health status or medical care, including medical and hospital records.
5. To consent to the donation of the Principal's organs for medical purposes, if so desired by the Principal.

Signature and Acknowledgement:

This Medical Power of Attorney will not be valid unless it is signed by the Principal or in the Principal's explicit direction. The signature should preferably be witnessed by two adults who are not named as the agent or successor agent.

Principal's Signature: ___________________________ Date: ____________

Witness 1 Signature: ___________________________ Date: ____________

Print Name: ___________________________________

Witness 2 Signature: ___________________________ Date: ____________

Print Name: ___________________________________

This document revokes any prior Medical Power of Attorney documents signed by the Principal. However, this does not affect the financial powers of attorney, which are separate documents.

It is advised to review this document regularly and update as necessary to ensure it continues to reflect the Principal's wishes.