Ch. 545                                    1996 LAWS OF MARYLAND

(4) 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; or

______ When this document is signed.

(5) 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)  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.

(Date)                                                                    (Signature of Declarant)

The declarant signed or acknowledged signing this appointment of a health care
agent in my presence and based upon my personal observation appears to be a competent
individual.

(Signature of two witnesses)

Part B

Advance Medical Directive

Health Care Instructions

(Optional Form)

(Cross through if you do not want to complete this portion of the form. If you do want to
complete this portion of the form, initial those statements you want to be included in the
document and cross through those statements that do not apply.)

If I am incapable of making an informed decision regarding my health care, I direct my
health care providers to follow my instructions as set forth below. (Initial all those that
apply.)

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(Witness)

(Witness)