PARRIS N. GLENDENING, Governor

Ch. 545

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 _________________

appoint the following individual as my agent to make health care decisions for me

(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

(Full Name, Address, and Telephone Number)

(2) My agent has full power and authority to make health care decisions for me, including
the power to:

a.  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
consent to disclosure of this information;

b.       Employ and discharge my heath 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) The authority of my agent is subject to the following provisions and limitations:

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