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2005 LAWS OF MARYLAND
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Ch. 137
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a. [Request,] IN ACCORDANCE WITH THE HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY ACT AND AS MY PERSONAL REPRESENTATIVE, REQUEST,
receive, and review any information, oral or written, regarding my physical or
mental health, including, but not limited to, medical and hospital records, AND
OTHER PROTECTED HEALTH INFORMATION, and consent to disclosure of this
information;
b. Employ and discharge my health care providers;
c. Authorize my admission to or discharge from (including transfer to another
facility) any hospital, hospice, nursing home, adult home, or other medical care
facility; and
d. Consent to the provision, withholding, or withdrawal of health care,
including, in appropriate circumstances, life-sustaining procedures.
(3) (4) The authority of my agent is subject to the following provisions and
limitations:
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____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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(4) (5) My agent's authority becomes operative (initial the option that applies):
______ When my attending physician and a second physician determine that I am
incapable of making an informed decision regarding my health care, PROVIDED
HOWEVER, WHEN THIS DOCUMENT IS SIGNED, EACH INDIVIDUAL IDENTIFIED IN
PARAGRAPH (1) IS, IN ACCORDANCE WITH THE HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY ACT, MY PERSONAL REPRESENTATIVE FOR ALL PURPOSES
RELATED TO ANY ASSESSMENT OF MY CAPACITY TO MAKE AN INFORMED DECISION
REGARDING MY HEALTH CARE; or
______ When this document is signed.
(5) (6) My agent is to make health care decisions for me based on the health care
instructions I give in this document and on my wishes as otherwise known to my
agent. If my wishes are unknown or unclear, my agent is to make health care
decisions for me in accordance with my best interest, to be determined by my agent
after considering the benefits, burdens, and risks that might result from a given
treatment or course of treatment, or from the withholding or withdrawal of a
treatment or course of treatment.
(6) (7) My agent shall not be liable for the costs of care based solely on this
authorization.
By signing below, I indicate that I am emotionally and mentally competent to
make this appointment of a health care agent and that I understand its purpose and
effect.
- 958 -
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