HEALTH CARE POWER OF ATTORNEY
(Maryland – Durable Advance Directive)
[// GUIDANCE: This template satisfies the Maryland Health Care Decisions Act, Md. Code Ann., Health–Gen. § 5-601 et seq., and embeds HIPAA-compliant authorization language (45 C.F.R. §§ 160 & 164). Customize bracketed terms, review optional provisions, and confirm execution formalities before use.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Appointment of Health Care Agent
3.2 Scope of Authority
3.3 End-of-Life Instructions
3.4 HIPAA Authorization
3.5 Organ & Anatomical Gifts (Optional) - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
- Witness Attestation & Acknowledgment
1. DOCUMENT HEADER
THIS HEALTH CARE POWER OF ATTORNEY (this “Directive”) is executed as of [EFFECTIVE DATE] (the “Effective Date”) by [PRINCIPAL LEGAL NAME], residing at [PRINCIPAL ADDRESS] (the “Principal”), pursuant to the Maryland Health Care Decisions Act and other applicable state and federal law.
Recitals:
A. The Principal desires to ensure that health care decisions continue to be made in accordance with the Principal’s wishes if the Principal becomes incapable of making or communicating such decisions.
B. The Principal is of sound mind and is executing this Directive voluntarily and without duress or undue influence.
2. DEFINITIONS
For purposes of this Directive, the following capitalized terms shall have the meanings set forth below:
“Agent” means the individual(s) designated in Section 3.1 to act on the Principal’s behalf regarding Health Care Decisions.
“Alternate Agent” means the individual(s) designated to serve if the Primary Agent is unable, unwilling, or ineligible to serve.
“Attending Physician” means the physician who has primary responsibility for the Principal’s health care.
“End-Stage Condition” has the meaning provided in Md. Code Ann., Health–Gen. § 5-601.
“Health Care Decision” means any consent, refusal, withdrawal, or request related to the Principal’s medical treatment, placement, service, or procedure.
“HIPAA” means the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, including 45 C.F.R. parts 160 and 164.
“Persistent Vegetative State” has the meaning provided in Md. Code Ann., Health–Gen. § 5-601.
“Terminal Condition” has the meaning provided in Md. Code Ann., Health–Gen. § 5-601.
[// GUIDANCE: Add any practice- or client-specific definitions here.]
3. OPERATIVE PROVISIONS
3.1 Appointment of Health Care Agent
a. Primary Agent. The Principal hereby appoints [PRIMARY AGENT NAME], whose contact information is [PRIMARY AGENT CONTACT], as the Principal’s lawful Agent to make Health Care Decisions.
b. Alternate Agent(s). If the Primary Agent is unavailable, unwilling, or ineligible to serve, the Principal appoints the following, in the order listed, as Alternate Agents:
1. [FIRST ALTERNATE NAME], [CONTACT INFO]
2. [SECOND ALTERNATE NAME], [CONTACT INFO]
3.2 Scope of Authority
Subject to the limitations set forth herein, the Agent is authorized to:
1. Consent to, refuse, or withdraw consent to any medical care, treatment, service, or procedure, including life-sustaining procedures;
2. Employ or discharge health care providers;
3. Arrange for the Principal’s admission to or discharge from hospitals, nursing homes, or other facilities;
4. Review and obtain copies of any medical records and information protected under HIPAA;
5. Execute documents required by any health care facility, payer, or governmental agency.
[// GUIDANCE: Include or exclude mental-health-specific authority as appropriate.]
3.3 End-of-Life Instructions
The Principal’s preferences regarding life-sustaining treatment are as follows (check ONE box under each scenario):
A. Terminal Condition
☐ I direct that life-sustaining procedures be continued.
☐ I direct that life-sustaining procedures be withheld or withdrawn.
☐ I defer decision-making to my Agent.
B. Persistent Vegetative State
☐ Continue life-sustaining procedures.
☐ Withhold or withdraw life-sustaining procedures.
☐ Defer to Agent.
C. End-Stage Condition
☐ Continue life-sustaining procedures.
☐ Withhold or withdraw life-sustaining procedures.
☐ Defer to Agent.
[// GUIDANCE: Maryland recognizes organ donation, comfort care, and pain management instructions. Insert additional preferences as needed.]
3.4 HIPAA Authorization
Pursuant to 45 C.F.R. § 164.502(g)(2) and corresponding regulations, the Principal authorizes any covered entity to disclose to the Agent any individually identifiable health information, including mental health and substance-use information, to the extent necessary for the Agent to carry out the authority granted herein. This authorization is effective upon execution and shall remain in effect until revoked in writing.
3.5 Organ & Anatomical Gifts (Optional)
☐ I DO NOT wish to make any anatomical gifts.
☐ I AUTHORIZE my Agent to consent to organ and tissue donation.
☐ I SPECIFICALLY DONATE the following organs/tissues: [SPECIFY].
4. REPRESENTATIONS & WARRANTIES
4.1 Principal’s Capacity. The Principal represents being at least eighteen (18) years of age, of sound mind, and under no constraint or undue influence.
4.2 Agent Qualifications. Each Agent warrants being at least eighteen (18) years of age and not presently serving as one of the attesting witnesses to this Directive.
4.3 No Conflicting Directives. The Principal represents that any prior health care power of attorney is hereby revoked, except: [EXCEPTIONS, IF ANY].
5. COVENANTS & RESTRICTIONS
5.1 Agent Standard of Conduct. The Agent shall:
a. Act in accordance with the Principal’s known wishes and values;
b. Act in good faith, with reasonable diligence, and in the Principal’s best interests;
c. Maintain contemporaneous records of significant Health Care Decisions;
d. Avoid self-dealing or conflicts of interest unless expressly authorized herein.
5.2 Limitations. The Agent may NOT:
a. Authorize voluntary admission to a mental-health facility for more than seventy-two (72) hours without judicial approval;
b. Consent to experimental treatment unless (i) in the Principal’s best interest and (ii) consistent with the Principal’s expressed wishes;
c. Override any limitation expressly set forth in Section 3.3.
6. DEFAULT & REMEDIES
6.1 Revocation by Principal. The Principal may revoke this Directive in whole or in part at any time by:
a. A signed and dated writing;
b. An oral statement in the presence of a witness; or
c. Any other method recognized under Md. Code Ann., Health–Gen. § 5-604.
6.2 Removal of Agent. A person with standing (including a health care provider or family member) may petition the [FORUM SELECTION: MARYLAND PROBATE COURT] for removal of an Agent who is acting (i) outside the scope of authority, (ii) in bad faith, or (iii) contrary to the Principal’s known wishes.
6.3 Successor Appointment. Upon removal, resignation, or incapacity of the Agent, authority shall vest in the next-listed Alternate Agent; if none, Section 6.4 applies.
6.4 Judicial Appointment. If no qualified Agent is available, any interested person may petition for the appointment of a health care surrogate under Md. Code Ann., Health–Gen. § 5-605.
7. RISK ALLOCATION
7.1 Indemnification. The Principal agrees to indemnify and hold harmless any Agent who acts in good faith and within the scope of this Directive from liability for any claim arising out of such actions, except for willful misconduct or gross negligence.
7.2 Limitation of Liability. No Agent shall be liable for monetary damages in excess of the value of the Principal’s estate at the time the cause of action arises, provided the Agent has acted in good faith.
7.3 Reliance. Any third party, including a health care provider, may rely upon a copy of this Directive and the Agent’s representations of authority without further inquiry, absent actual knowledge of revocation.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Directive is governed by the laws of the State of Maryland, without regard to conflict-of-law principles.
8.2 Forum Selection. Any action arising under or relating to this Directive shall be brought exclusively in the appropriate Maryland probate court.
8.3 Arbitration & Jury Waiver. Arbitration is not available under this Directive, and no contractual jury waiver is provided.
8.4 Injunctive Relief. The court may grant injunctive or declaratory relief necessary to effectuate health care directives herein.
9. GENERAL PROVISIONS
9.1 Amendment. The Principal may amend this Directive only by a writing executed with the same formalities as this Directive.
9.2 Severability. If any provision is held unenforceable, the remaining provisions shall remain in full force, and the Directive shall be construed to effectuate the Principal’s intent.
9.3 Integration. This Directive constitutes the entire agreement regarding the subject matter hereof, superseding any prior inconsistent directives.
9.4 Copies; Electronic Signatures. A photocopy, facsimile, or electronically signed copy of this Directive shall be as valid as an original.
9.5 Successors & Assigns. References to the Agent include any qualified successor appointed under Section 6.3.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the Principal has executed this Health Care Power of Attorney as of the Effective Date.
Principal:
[PRINCIPAL NAME]
Date: _______
11. WITNESS ATTESTATION & ACKNOWLEDGMENT
We, the undersigned witnesses, declare that (i) the Principal is personally known to us, (ii) the Principal signed or acknowledged the foregoing Directive in our presence, (iii) the Principal appears to be of sound mind and under no duress, fraud, or undue influence, and (iv) we are at least 18 years of age and are not the Agent, Alternate Agent, or knowingly entitled to any portion of the Principal’s estate.
Witness #1:
Name: [WITNESS 1 NAME]
Address: [ADDRESS]
Date: _______
Witness #2:
Name: [WITNESS 2 NAME]
Address: [ADDRESS]
Date: _______
[// GUIDANCE: Maryland does not require notarization; however, a notary block may facilitate recognition in other jurisdictions.]