Fill - Free fillable PLANNING FOR FUTURE HEALTH CARE DECISIONS (Maryland Attorney General) PDF form

MARYLAND ADVANCE DIRECTIVE:

PLANNING FOR FUTURE HEALTH CARE DECISIONS

STATE OF MARYLAND

OFFICE OF THE ATTORNEY GENERAL

Brian E. Frosh

Attorney General

August 2019

ii

Dear Fellow Marylander:

I am pleased to send you an advance directive form that you can use to plan

for future health care decisions. The form is optional; you can use it if you want or use

others, which are just as valid legally. If you have any legal questions about your

personal situation, you should consult your own lawyer. If you decide to make an

advance directive, be sure to talk about it with those close to you. The conversation is

just as important as the document. Give copies to family members or friends and

your doctor. Also make sure that, if you go into a hospital, you bring a copy. Please

do not return completed forms to this office.

Life-threatening illness is a difficult subject to deal with. If you plan now,

however, your choices can be respected and you can relieve at least some of the

burden from your loved ones in the future. You may also use another enclosed form

to make an organ donation or plan for arrangements after death.

Here is some related, important information:

• If you want information about Do Not Resuscitate (DNR) Orders, please

visit the website http://marylandmolst.org or contact the Maryland

Institute for Emergency Medical Services Systems directly at (410) 706-

4367. A Medical Orders for Life-Sustaining Treatment (MOLST) form

contains medical orders regarding cardiopulmonary resuscitation (CPR)

and other medical orders regarding life-sustaining treatments. A

physician or nurse practitioner may use a MOLST form to instruct

emergency medical personnel (911 responders) to provide comfort care

instead of resuscitation. The MOLST form can be found on the Internet

at: http://marylandmolst.org. From that page, click on “MOLST Form.”

• The Maryland Department of Health makes available an advance

directive focused on preferences about mental health treatment. This

can be found on the Internet at:

https://bha.health.maryland.gov/Pages/Forms.aspx. From that page,

under “Forms,” click on “Advance Directive for Mental Health

Treatment.”

I hope that this information is helpful to you. I regret that overwhelming

demand limits us to supplying one set of forms to each requester. But please feel

free to make as many copies as you wish. Additional information about advance

directives can be found on the Internet at:

http://www.oag.state.md.us/healthpol/advancedirectives.htm.

Brian E. Frosh

Attorney General

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HEALTH CARE PLANNING

USING ADVANCE DIRECTIVES

Optional Form Included

Your Right To Decide

Adults can decide for themselves

whether they want medical treatment.

This right to decide - to say yes or no to

proposed treatment - applies to

treatments that extend life, like a

breathing machine or a feeding tube.

Tragically, accident or illness can take

away a person's ability to make health care

decisions. But decisions still have to be

made. If you cannot do so, someone else

will. These decisions should reflect your

own values and priorities.

A Maryland law called the Health Care

Decisions Act says that you can do health

care planning through “advance

directives.” An advance directive can be

used to name a health care agent. This is

someone you trust to make health care

decisions for you. An advance directive can

also be used to say what your preferences

are about treatments that might be used to

sustain your life.

The State offers a form to do this

planning, included with this pamphlet. The

form as a whole is called “Maryland

Advance Directive: Planning for Future

Health Care Decisions.” It has three parts

to it: Part I, Selection of Health Care Agent;

Part II, Treatment Preferences (“Living

Will”); and Part III, Signature and

Witnesses. This pamphlet will explain

each part.

The advance directive is meant to

reflect your preferences. You may

complete all of it, or only part, and you may

change the wording. You are not required

by law to use these forms. Different forms,

written the way you want, may also be

used. For example, one widely praised

form, called Five Wishes, is available (for a

small fee) from the nonprofit organization

Aging With Dignity. You can get

information about that document from the

Internet at www.agingwithdignity.org or

write to: Aging with Dignity, P.O. Box 1661,

Tallahassee, FL 32302.

This optional form can be filled out

without going to a lawyer. But if there is

anything you do not understand about the

law or your rights, you might want to talk

with a lawyer. You can also ask your

doctor to explain the medical issues,

including the potential benefits or risks to

you of various options. You should tell

your doctor that you made an advance

directive and give your doctor a copy,

along with others who could be involved in

making these decisions for you in the

future.

In Part III of the form, you need two

witnesses to your signature. Nearly any

adult can be a witness. If you name a health

care agent, though, that person may not be

a witness. Also, one of the witnesses must

be a person who would not financially

benefit by your death or handle your

estate. You do not need to have the form

notarized.

This pamphlet also contains a separate

form called “After My Death.” Like the

advance directive, using it is optional. This

form has four parts to it: Part I, Organ

Donation; Part II, Donation of Body; Part

III, Disposition of Body and Funeral

Arrangements; and Part IV, Signature and

Witnesses.

Once you make an advance directive, it

remains in effect unless you revoke it. It

does not expire, and neither your family

nor anyone except you can change it. You

should review what you've done once in a

while. Things might change in your life, or

your attitudes might change. You are free

to amend or revoke an advance directive

at any time, as long as you still have

decision-making capacity. Tell your doctor

and anyone else who has a copy of your

advance directive if you amend it or

revoke it.

If you already have a prior Maryland

advance directive, living will, or a durable

iv

power of attorney for health care, that

document is still valid. Also, if you made an

advance directive in another state, it is

valid in Maryland. You might want to

review these documents to see if you

prefer to make a new advance directive

instead.

Part I of the Advance Directive:

Selection of Health Care Agent

You can name anyone you want (except,

in general, someone who works for a health

care facility where you are receiving care) to

be your health care agent. To name a health

care agent, use Part I of the advance

directive form. (Some people refer to this

kind of advance directive as a “durable

power of attorney for health care.”) Your

agent will speak for you and make decisions

based on what you would want done or your

best interests. You decide how much power

your agent will have to make health care

decisions. You can also decide when you

want your agent to have this power ─ right

away, or only after a doctor says that you are

not able to decide for yourself.

You can pick a family member as a health

care agent, but you don't have to. Remember,

your agent will have the power to make

important treatment decisions, even if other

people close to you might urge a different

decision. Choose the person best qualified to

be your health care agent. Also, consider

picking one or two back-up agents, in case

your first choice isn’t available when needed.

Be sure to inform your chosen person and

make sure that he or she understands what’s

most important to you. When the time comes

for decisions, your health care agent should

follow your written directions.

We have a helpful booklet that you can

give to your health care agent. It is called

“Making Medical Decisions for Someone Else:

A Maryland Handbook.” You or your agent

can get a copy on the Internet at:

http://www.marylandattorneygeneral.gov/

Health%20Policy%20Documents/ProxyHan

dbook.pdf. You can request a copy by calling

410-576-7000.

The form included with this pamphlet

does not give anyone power to handle your

money. We do not have a standard form to

send. Talk to your lawyer about planning for

financial issues in case of incapacity.

Part II of the Advance Directive:

Treatment Preferences

(“Living Will”)

You have the right to use an advance

directive to say what you want about future

life-sustaining treatment issues. You can do

this in Part II of the form. If you both name a

health care agent and make decisions about

treatment in an advance directive, it’s

important that you say (in Part II, paragraph

G) whether you want your agent to be strictly

bound by whatever treatment decisions you

make.

Part II is a living will. It lets you decide

about life-sustaining procedures in three

situations: when death from a terminal

condition is imminent despite the

application of life-sustaining procedures; a

condition of permanent unconsciousness

called a persistent vegetative state; and end-

stage condition, which is an advanced,

progressive, and incurable condition

resulting in complete physical dependency.

One example of end-stage condition could be

advanced Alzheimer's disease.

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FREQUENTLY ASKED QUESTIONS ABOUT

ADVANCE DIRECTIVES IN MARYLAND

1. Must I use any particular form?

No. An optional form is provided, but you may

change it or use a different form altogether. Of

course, no health care provider may deny you care

simply because you decided not to fill out a form.

2. Who can be picked as a health care agent?

Anyone who is 18 or older except, in general,

an owner, operator, or employee of a health care

facility where a patient is receiving care.

3. Who can witness an advance directive?

Two witnesses are needed. Generally, any

competent adult can be a witness, including your

doctor or other health care provider (but be aware

that some facilities have a policy against their

employees serving as witnesses). If you name a

health care agent, that person cannot be a witness

for your advance directive. Also, one of the two

witnesses must be someone who (i) will not receive

money or property from your estate and (ii) is not

the one you have named to handle your estate after

your death.

4. Do the forms have to be notarized?

No, but if you travel frequently to another

state, check with a knowledgeable lawyer to see if

that state requires notarization.

5. Do any of these documents deal with

financial matters?

No. If you want to plan for how financial

matters can be handled if you lose capacity, talk

with your lawyer.

6. When using these forms to make a decision,

how do I show the choices that I have made?

Write your initials next to the statement that

says what you want. Don't use checkmarks or X's. If

you want, you can also draw lines all the way

through other statements that do not say what you

want.

7. Should I fill out both Parts I and II

of the advance directive form?

It depends on what you want to do. If all you

want to do is name a health care agent, just fill out

Parts I and III, and talk to the person about how

they should decide issues for you. If all you want to

do is give treatment instructions, fill out Parts II and

III. If you want to do both, fill out all three parts.

8. Are these forms valid in another state?

It depends on the law of the other state. Most

state laws recognize advance directives made

somewhere else.

9. How can I get advance directive forms for

another state?

Contact the National Hospice and Palliative

Care Organization (NHPCO) at 1-800-658-8898 or

on the Internet at:

https://www.nhpco.org/patients-and-

caregivers/advance-care-planning/advance-

directives/downloading-your-states-advance-

directive/

10. To whom should I give copies of my advance

directive?

Give copies to your doctor, your health care

agent and backup agent(s), hospital or nursing

home if you will be staying there, and family

members or friends who should know of your

wishes. Consider carrying a card in your wallet

saying you have an advance directive and who to

contact.

11. Does the federal law on medical records

privacy (HIPAA) require special language

about my health care agent?

Special language is not required, but it is

prudent. Language about HIPAA has been

incorporated into the form.

12. Can my health care agent or my family

decide treatment issues differently from

what I wrote?

It depends on how much flexibility you want

to give. Some people want to give family members

or others flexibility in applying the living will. Other

people want it followed very strictly. Say what you

want in Part II, Paragraph G.

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13. Is an advance directive the same as a

“Patient’s Plan of Care”, “Instructions on

Current Life-Sustaining Treatment Options”

form, or Medical Orders for Life-Sustaining

Treatment (MOLST) form?

No. These are forms used in health care

facilities to document discussions about current

life-sustaining treatment issues. These forms are

not meant for use as anyone’s advance directive.

Instead, they are medical records, to be done only

when a doctor or other health care professional

presents and discusses the issues. A MOLST form

contains medical orders regarding life-sustaining

treatments relating to a patient’s medical condition.

14. Can my doctor override my living will?

Usually, no. However, a doctor is not required

to provide a “medically ineffective” treatment even

if a living will asks for it.

15. If I have an advance directive, do I also need

a MOLST form?

It depends. If you don't want emergency

medical services personnel to try to resuscitate you

in the event of cardiac or respiratory arrest, you

must have a MOLST form containing a DNR order

signed by your doctor. nurse practitioner, or

physician assistant. A signed EMS/DNR order

approved by the Maryland Institute for Emergency

Medical Services Systems would also be valid.

16. Does the DNR Order have to be in a

particular form?

Yes. Emergency medical services personnel

have very little time to evaluate the situation and

act appropriately. So, it is not practical to ask them

to interpret documents that may vary in form and

content. Instead, the standardized MOLST form has

been developed. Have your doctor or health care

facility visit the MOLST web site at

http://marylandmolst.org or contact the Maryland

Institute for Emergency Medical Services System at

(410) 706-4367 to obtain information on the

MOLST form.

17. Can I fill out a form to become an organ

donor?

18. What about donating my body for medical

education or research?

Part II of the “After My Death” form is a

general statement of these wishes. The State

Anatomy Board has a specific donation program,

with a pre-registration form available. Call the

Anatomy Board at 1-800-879-2728 for that form

and additional information.

19. If I appoint a health care agent and the

health care agent and any back-up agent

dies or otherwise becomes unavailable, a

surrogate decision maker may need to be

consulted to make the same treatment

decisions that my health care agent would

have made. Is the surrogate decision maker

required to follow my instructions given in

the advance directive?

Yes, the surrogate decision maker is required

to make treatment decisions based on your known

wishes. An advance directive that contains clear

and unambiguous instructions regarding treatment

options is the best evidence of your known wishes

and therefore must be honored by the surrogate

decision maker.

Part II, paragraph G enables you to choose one

of two options with regard to the degree of

flexibility you wish to grant the person who will

ultimately make treatment decisions for you,

whether that person is a health care agent or a

surrogate decision maker. Under the first option

you would instruct the decision maker that your

stated preferences are meant to guide the decision

maker but may be departed from if the decision

maker believes that doing so would be in your best

interests. The second option requires the decision

maker to follow your stated preferences strictly,

even if the decision maker thinks some alternative

would be better.

REVISED AUGUST 2019

Yes, Use Part I of the “After My Death” form.

I

F YOU HAVE OTHER QUESTIONS

,

PLEASE TALK TO YOUR DOCTOR

OR YOUR LAWYER

. OR, IF YOU HAVE A QUESTION ABOUT THE

FORMS THAT IS NOT ANSWERED IN THIS PAMPHLET

, YOU CAN

CALL THE

HEALTH POLICY DIVISION OF THE ATTORNEY

GENERAL’S OFFICE AT (410) 767-6918 OR E-

MAIL US AT

ADFORMS@OAG.STATE.MD.US. M

ORE INFORMATION ABOUT

ADVANCE DIRECTIVES CAN BE OBTAINED FROM OUR WEBSITE AT:

http://www.marylandattorneygeneral.gov/Pages/HealthPo

licy/advancedirectives.aspx

Page 1 of 8

By: Date of Birth:

(Print Name) (Month/Day/Year)

Using this advance directive form to do health care planning is completely optional.

Other forms are also valid in Maryland. No matter what form you use, talk to your family

and others close to you about your wishes.

This form has two parts to state your wishes, and a third part for needed signatures.

Part I of this form lets you answer this question: If you cannot (or do not want to) make

your own health care decisions, who do you want to make them for you? The person you

pick is called your health care agent. Make sure you talk to your health care agent (and

any back-up agents) about this important role. Part II lets you write your preferences

about efforts to extend your life in three situations: terminal condition, persistent

vegetative state, and end-stage condition. In addition to your health care planning

decisions, you can choose to become an organ donor after your death by filling out the form

for that too.

➔ You can fill out Parts I and II of this form, or only Part I, or only Part II. Use the form to

reflect your wishes, then sign in front of two witnesses (Part III). If your wishes change,

make a new advance directive.

Make sure you give a copy of the completed form to your health care agent, your

doctor, and others who might need it. Keep a copy at home in a place where someone can

get it if needed. Review what you have written periodically.

PART I: SELECTION OF HEALTH CARE AGENT

A. Selection of Primary Agent

I select the following individual as my agent to make health care decisions for me:

Name:

Address:

Telephone Numbers:

(home and cell)

MARYLAND ADVANCE DIRECTIVE:

P

LANNING FOR FUTURE HEALTH CARE DECISIONS

Page 2 of 8

B. Selection of Back-up Agents

(Optional; form valid if left blank)

1. If my primary agent cannot be contacted in time or for any reason is unavailable or

unable or unwilling to act as my agent, then I select the following person to act in this

capacity:

Name:

Address:

Telephone Numbers:

(home and cell)

2. If my primary agent and my first back-up agent cannot be contacted in time or for any

reason are unavailable or unable or unwilling to act as my agent, then I select the

following person to act in this capacity:

Name:

Address:

Telephone Numbers:

(home and cell)

C. Powers and Rights of Health Care Agent

I want my agent to have full power to make health care decisions for me, including the

power to:

1. Consent or not to medical procedures and treatments which my doctors offer, including

things that are intended to keep me alive, like ventilators and feeding tubes;

2. Decide who my doctor and other health care providers should be; and

3. Decide where I should be treated, including whether I should be in a hospital, nursing

home, other medical care facility, or hospice program.

4. I also want my agent to:

a. Ride with me in an ambulance if ever I need to be rushed to the hospital; and

b. Be able to visit me if I am in a hospital or any other health care facility.

THIS ADVANCE DIRECTIVE DOES NOT MAKE MY AGENT

RESPONSIBLE FOR ANY OF THE COSTS OF MY CARE.

Page 3 of 8

This power is subject to the following conditions or limitations:

(Optional; form valid if left blank)

D. How my Agent is to Decide Specific Issues

I trust my agent’s judgment. My agent should look first to see if there is anything in Part II

of this advance directive that helps decide the issue. Then, my agent should think about the

conversations we have had, my religious and other beliefs and values, my personality, and

how I handled medical and other important issues in the past. If what I would decide is still

unclear, then my agent is to make decisions for me that my agent believes are in my best

interest. In doing so, my agent should consider the benefits, burdens, and risks of the

choices presented by my doctors.

E. People My Agent Should Consult

(Optional; form valid if left blank)

In making important decisions on my behalf, I encourage my agent to consult with the

following people. By filling this in, I do not intend to limit the number of people with whom

my agent might want to consult or my agent’s power to make decisions.

Name(s) Telephone Number(s):

F. In Case of Pregnancy

(Optional, for women of child-bearing years only; form valid if left blank)

If I am pregnant, my agent shall follow these specific instructions:

Page 4 of 8

G. Access to my Health Information – Federal Privacy Law (HIPAA) Authorization

1. If, prior to the time the person selected as my agent has power to act under this

document, my doctor wants to discuss with that person my capacity to make my own

health care decisions, I authorize my doctor to disclose protected health information

which relates to that issue.

2. Once my agent has full power to act under this document, my agent may 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.

3. For all purposes related to this document, my agent is my personal representative

under the Health Insurance Portability and Accountability Act (HIPAA). My agent may

sign, as my personal representative, any release forms or other HIPAA-related

materials.

H. Effectiveness of this Part

(Read both of these statements carefully. Then, initial one only.)

My agent’s power is in effect:

1. Immediately after I sign this document, subject to my right to make any decision about

my health care if I want and am able to.

✎______________

>>OR<<

2. Whenever I am not able to make informed decisions about my health care, either

because the doctor in charge of my care (attending physician) decides that I have lost

this ability temporarily, or my attending physician and a consulting doctor agree that I

have lost this ability permanently.

✎__________

If the only thing you want to do is select a health care agent,

skip Part II. Go to Part III to sign and have the advance directive

witnessed. If you also want to write your treatment preferences,

go to Part II. Also consider becoming an organ donor, using the

separate form for that.

Page 5 of 8

PART II: TREATMENT PREFERENCES (“LIVING WILL”)

A. Statement of Goals and Values

(Optional: Form valid if left blank)

I want to say something about my goals and values, and especially what’s most important to

me during the last part of my life:

B. Preference in Case of Terminal Condition

(If you want to state what your preference is, initial one only. If you do not want to state a

preference here, cross through the whole section.)

If my doctors certify that my death from a terminal condition is imminent, even if life-

sustaining procedures are used:

1. Keep me comfortable and allow natural death to occur. I do not want any medical

interventions used to try to extend my life. I do not want to receive nutrition and fluids

by tube or other medical means.

✎______________

>>OR<<

2. Keep me comfortable and allow natural death to occur. I do not want medical

interventions used to try to extend my life. If I am unable to take enough nourishment

by mouth, however, I want to receive nutrition and fluids by tube or other medical

means.

✎______________

>>OR<<

3. Try to extend my life for as long as possible, using all available interventions that in

reasonable medical judgment would prevent or delay my death. If I am unable to take

enough nourishment by mouth, I want to receive nutrition and fluids by tube or other

medical means.

✎______________

Page 6 of 8

C. Preference in Case of Persistent Vegetative State

(If you want to state what your preference is, initial one only. If you do not want to state a

preference here, cross through the whole section.)

If my doctors certify that I am in a persistent vegetative state, that is, if I am not

conscious and am not aware of myself or my environment or able to interact with

others, and there is no reasonable expectation that I will ever regain consciousness:

1. Keep me comfortable and allow natural death to occur. I do not want any medical

interventions used to try to extend my life. I do not want to receive nutrition and fluids

by tube or other medical means.

✎______________

>>OR<<

2. Keep me comfortable and allow natural death to occur. I do not want medical

interventions used to try to extend my life. If I am unable to take enough nourishment

by mouth, however, I want to receive nutrition and fluids by tube or other medical

means.

✎______________

>>OR<<

3. Try to extend my life for as long as possible, using all available interventions that in

reasonable medical judgment would prevent or delay my death. If I am unable to take

enough nourishment by mouth, I want to receive nutrition and fluids by tube or other

medical means.

✎______________

D. Preference in Case of End-Stage Condition

(If you want to state what your preference is, initial one only. If you do not want to state a

preference here, cross through the whole section.)

If my doctors certify that I am in an end-stage condition, that is, an incurable

condition that will continue in its course until death and that has already resulted in

loss of capacity and complete physical dependency:

1. Keep me comfortable and allow natural death to occur. I do not want any medical

interventions used to try to extend my life. I do not want to receive nutrition and fluids

by tube or other medical means.

✎_____________

>>OR<<

2. Keep me comfortable and allow natural death to occur. I do not want medical

interventions used to try to extend my life. If I am unable to take enough nourishment

by mouth, however, I want to receive nutrition and fluids by tube or other medical

means.

✎______________

>>OR<<

3. Try to extend my life for as long as possible, using all available interventions that in

reasonable medical judgment would prevent or delay my death. If I am unable to take

enough nourishment by mouth, I want to receive nutrition and fluids by tube or other

medical means.

✎______________

Page 7 of 8

E. Pain Relief

No matter what my condition, give me the medicine or other treatment I need to relieve

pain.

F. In Case of Pregnancy

(Optional, for women of child-bearing years only; form valid if left blank)

If I am pregnant, my decision concerning life-sustaining procedures shall be modified as

follows:

G. Effect of Stated Preferences

(Read both of these statements carefully. Then, initial one only.)

1. I realize I cannot foresee everything that might happen after I can no longer decide for

myself. My stated preferences are meant to guide whoever is making decisions on my

behalf and my health care providers, but I authorize them to be flexible in applying

these statements if they feel that doing so would be in my best interest.

✎______________

>>OR <<

2. I realize I cannot foresee everything that might happen after I can no longer decide for

myself. Still, I want whoever is making decisions on my behalf and my health care

providers to follow my stated preferences exactly as written, even if they think that

some alternative is better.

✎______________

Page 8 of 8

PART III: SIGNATURE AND WITNESSES

By signing below as the Declarant, I indicate that I am emotionally and mentally competent

to make this advance directive and that I understand its purpose and effect. I also

understand that this document replaces any similar advance directive I may have

completed before this date.

(Signature of Declarant) (Date)

The Declarant signed or acknowledged signing this document in my presence and, based

upon personal observation, appears to be emotionally and mentally competent to make

this advance directive.

(Signature of Witness) (Date)

Telephone Number(s):

(Signature of Witness) (Date)

Telephone Number(s):

(Note: Anyone selected as a health care agent in Part I may not be a witness. Also, at least

one of the witnesses must be someone who will not knowingly inherit anything from the

Declarant or otherwise knowingly gain a financial benefit from the Declarant’s death.

Maryland law does not require this document to be notarized.

Page 1 of 2

By: Date of Birth:

(Print Name) (Month/Day/Year)

PART I: ORGAN DONATION

(Initial the ones that you want. Cross through any that you do not want.)

Upon my death I wish to donate: ✎

Any needed organs, tissues, or eyes. ✎

Only the following organs, tissues or eyes:

I authorize the use of my organs, tissues, or eyes:

For transplantation ✎

For therapy ✎

For research ✎

For medical education ✎

For any purpose authorized by law ✎

I understand that no vital organ, tissue, or eye may be removed for transplantation

until after I have been pronounced dead. This document is not intended to change anything

about my health care while I am still alive. After death, I authorize any appropriate support

measures to maintain the viability for transplantation of my organs, tissues, and eyes until

organ, tissue, and eye recovery has been completed. I understand that my estate will not be

charged for any costs related to this donation.

PART II: DONATION OF BODY

After any organ donation indicated in Part I, I wish my body to be donated for use in

a medical study program.

✎______________

AFTER MY DEATH

(This document is optional. Do only what reflects your wishes.)

Page 2 of 2

PART III: DISPOSITION OF BODY AND FUNERAL ARRANGEMENTS

I want the following person to make decisions about the disposition of my body and

my funeral arrangements: (Either initial the first or fill in the second.)

The health care agent who I named in my advance directive.

✎______________

>>OR<<

This person:

Name:

Address:

Telephone Number(s):

(Home and Cell)

If I have written my wishes below, they should be followed. If not, the person I have named

should decide based on conversations we have had, my religious or other beliefs and

values, my personality, and how I reacted to other peoples’ funeral arrangements. My

wishes about the disposition of my body and my funeral arrangements are:

PART IV: SIGNATURE AND WITNESSES

By signing below, I indicate that I am emotionally and mentally competent to make this

donation and that I understand the purpose and effect of this document.

(Signature of Donor) (Date)

The Donor signed or acknowledged signing the foregoing document in my presence and,

based upon personal observation, appears to be emotionally and mentally competent to

make this donation.

(Signature of Witness) (Date)

Telephone Number(s):

(Signature of Witness) (Date)

Telephone Number(s):

AFTER MY DEATH

Part II: Donation of Body

The State Anatomy Board, a unit of the Department of Health

administers a statewide Body Donation Program. Anatomical

Donation allows individuals to dedicate the use of their bodies upon

death to advance medical education, clinical and allied-health

training and research study to Maryland’s medical study institutions.

The Anatomy Board requires individuals to pre-register prior to death

as an anatomical donor to the state Body Donation Program. There

are no medical restrictions or qualifications to becoming a “Body

Donor”. At death the Board will assume the custody and control of

the body for study use. It is truly a legacy left behind for others to

have healthier lives. For donation information and forms you can

contact the Board toll-free at 800.879.2728

Did You Remember To ...

□ Fill out Part I if you want to name a health care agent?

□ Name one or two back-up agents in case your first choice as

health care agent is not available when needed?

□ Talk to your agents and back-up agent about your values and

priorities, and decide whether that’s enough guidance or

whether you also want to make specific health care decisions

in the advance directive?

□ If you want to make specific decisions, fill out Part II, choosing

carefully among alternatives?

□ Sign and date the advance directive in Part III, in front of two

witnesses who also need to sign?

□ Look over the “After My Death” form to see if you want to fill

out any part of it?

□ Make sure your health care agent (if you named one), your

family, and your doctor know about your advance care

planning?

□

Give a copy of your advance directive to your health care

agent, family members, doctor, and hospital or nursing home

if you are a patient there?

Fill Online, Printable, Fillable, Blank PLANNING FOR FUTURE HEALTH CARE DECISIONS (Maryland Attorney General) Form

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Fillable PLANNING FOR FUTURE HEALTH CARE DECISIONS (Maryland Attorney General)

Fill Online, Printable, Fillable, Blank PLANNING FOR FUTURE HEALTH CARE DECISIONS (Maryland Attorney General) Form

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