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ROBERT L. EHRLICH, JR., Governor
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Ch. 137
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(Signature of Two Witnesses)
Form II
Advance Directive
Part A
Appointment of Health Care Agent
(Optional Form)
(Cross through if you do not want to appoint a health care agent to make health care
decisions for you. If you do want to appoint an agent, cross through any items in the
form that you do not want to apply.)
(1) I, ______________________________________, residing at _________________
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____________________________________________________________________________
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appoint the following individual as my agent to make health care decisions for me
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____________________________________________________________________________
____________________________________________________________________________
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(Full Name, Address, and Telephone Number)
Optional: If this agent is unavailable or is unable or unwilling to act as my agent,
then I appoint the following person to act in this capacity
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_____________________________________________________________________________
_____________________________________________________________________________
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(Full Name, Address, and Telephone Number)
(2) IN ACCORDANCE WITH THE HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT, A HEALTH CARE AGENT IS A PERSONAL REPRESENTATIVE
AND IS ENTITLED TO REQUEST AND RECEIVE PROTECTED HEALTH INFORMATION.
(3) My agent has full power and authority to make health care decisions for me,
including the power to:
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- 957 -
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