Volume 772, Page 2046 View pdf image |
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Ch. 372 1993 LAWS OF MARYLAND (DATE)_____________________________________________(SIGNATURE OF DECLARANT) THE DECLARANT SIGNED OR ACKNOWLEDGED SIGNING THIS LIVING WILL IN (WITNESS)_____________________________________________(WITNESS) (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 (1) I, , RESIDING AT _____________________ APPOINT THE FOLLOWING INDIVIDUAL AS MY AGENT TO MAKE HEALTH CARE (FULL NAME, ADDRESS, AND TELEPHONE NUMBER) OPTIONAL: IF THIS AGENT IS UNAVAILABLE OR IS UNABLE OR UNWILLING TO ACT (FULL NAME, ADDRESS, AND TELEPHONE NUMBER) (2) MY AGENT HAS FULL POWER AND AUTHORITY TO MAKE HEALTH CARE A. REQUEST, RECEIVE, AND REVIEW ANY INFORMATION, ORAL OR - 2046 - ______________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
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Volume 772, Page 2046 View pdf image |
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