|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
ROBERT L. EHRLICH, JR., Governor
|
|
|
|
|
|
Ch. 522
|
|
|
|
|
|
|
|
|
|
|
|
|
DECISIONS, YOU CAN CHOOSE TO BECOME AN ORGAN DONOR AFTER YOUR DEATH
BY FILING 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 CAKE AGENT
A. SELECTION OF PRIMARY AGENT
I SELECT THE FOLLOWING INDIVIDUAL AS MY AGENT TO MAKE HEALTH CARE
DECISIONS FOR ME:
NAME:. _______________________________________________________________
ADDRESS: __________________'__________________________________________
|
|
|
|
|
|
|
|
|
|
TELEPHONE NUMBERS: ________________________________________________
(HOME AND CELL)
B. SELECTION OF BACK-UP AGENTS
(OPTIONAL; FORM VALID IF LEFT BLANK)
1. IF MY PRIMARY AGENT CANNOT BE CONTACTED IN TIME OR FOR ANY
REASON IS UNAVAILABLE OR UNABLE OR UNWILLING TO ACT AS MY AGENT,
THEN I SELECT THE FOLLOWING PERSON TO ACT IN THIS CAPACITY:
NAME: _______________________________________________________________
ADDRESS: ___________________________________________________
|
|
|
|
|
|
|
|
|
|
TELEPHONE NUMBERS: __________________________________________
(HOME AND CELL)
2. IF MY PRIMARY AGENT AND MY FIRST BACK-UP AGENT CANNOT BE
CONTACTED IN TIME OR FOR ANY REASON ARE UNAVAILABLE OR UNABLE
OR UNWILLING TO ACT AS MY AGENT, THEN I SELECT THE FOLLOWING
PERSON TO ACT IN THIS CAPACITY:
NAME: _________________________
ADDRESS: ____________________________________________________________
|
|
|
|
|
|
|
|
|
|
TELEPHONE NUMBERS: _______________________________
(HOME AND CELL)
C. POWERS AND RIGHTS OF HEALTH CARE AGENT
- 2585 -
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
