Maryland Medical Power of Attorney Template
This document serves as a Maryland Medical Power of Attorney, adhering to the laws of the State of Maryland. It allows you to appoint someone to make medical decisions on your behalf if you are unable to do so.
Principal Information:
- Name: ________________________________________
- Address: ______________________________________
- City, State, Zip: _______________________________
- Date of Birth: _________________________________
Agent Information:
- Name: ________________________________________
- Address: ______________________________________
- City, State, Zip: _______________________________
- Phone Number: _________________________________
Statement of Authority:
The Agent named above is authorized to make medical decisions on my behalf, including but not limited to:
- Choosing healthcare providers.
- Approving or rejecting medical treatments.
- Accessing my medical records.
Effective Date:
This Medical Power of Attorney shall become effective when I am unable to make informed healthcare decisions as determined by my doctor.
Revocation:
I reserve the right to revoke this document at any time. To do so, I will inform my Agent and any healthcare providers about my decision.
Signature:
Signed this _____ day of ____________, 20__.
___________________________________________
Signature of Principal
Witness Statement:
I hereby affirm that I witnessed the signing of this Medical Power of Attorney by the Principal.
___________________________________________
Signature of Witness
___________________________________________
Print Name of Witness
Date: ________________________________________
Notary Acknowledgement:
State of Maryland, County of ___________________
Subscribed and sworn to before me this _____ day of ____________, 20__.
___________________________________________
Notary Public
My Commission Expires: ________________________