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Legal Documents

Legal documents are needed at admission, discharge, prior to certain procedures and at surgery. Some documents you will provide to the hospital and some the hospital will provide for you to sign.

Admission Documents

The admission clerk will ask the patient or legal decision maker to complete and sign a form that includes the patient's basic demographic information (name, address, phone number) and insurance information. Your loved one's insurance information will be verified by the hospital staff. The patient, spouse or financial power of attorney will be asked to sign a form that indicates he or she accepts responsibility to pay for the services provided.

Your Documents

When completing the admission process, it is essential that you provide the hospital with any legal documents that give financial or medical consent responsibilities to another.

  • Financial Power of Attorney: The person named in this document is responsible for handling only the person's financial affairs described in the document (this may include payment of bills) if the patient is unable, or does not wish, to do so.
  • Advance Directives: These documents allow a person to make health care decisions in advance, so that those decisions may be carried out in the event that the person is no longer able to give informed consent. The advance directive may specify the type of care the person wants, and/or it may name another individual (the health care agent) to give informed consent for medical treatment. The admissions clerk will ask if the person has an advance directive or a living will (a type of advance directive). If so, a copy of this document must be placed in the patient's medical chart. If the person does not have an advance directive, the hospital staff will provide information on Advance Directives and Living Wills to the patient and, if they wish, the patient can complete these documents at the time of admission. Note: A hospital needs to notify the health care agent when there is a medical emergency or other problem requiring informed consent for treatment.
  • Order for Guardianship of the Person: This document indicates who was appointed to give informed consent for medical decisions for a person who was determined by the court to be “disabled” and therefore unable to give informed consent for medical decisions. If there is an order for guardianship of the person, bring a copy of the order to the hospital and have it placed in the patient's medical chart.
  • Order for Guardianship of the Property: This document indicates who was appointed to make financial decisions for a person who was determined by the court to be “disabled” and therefore unable to make financial decisions. If there is an order for guardianship of the property, bring a copy of the order to the hospital and have it placed in the patient's medical chart.
  • Do Not Resuscitate (DNR) Order: This document states that the person does not want to be revived if cardiac arrest occurs or if the person stops breathing. If the patient has a standing DNR (Do Not Resuscitate) order it is imperative that it be provided to the hospital. If the patient chooses, a DNR order can be initiated during his or her hospitalization.

A health care agent specified in an advance directive is responsible for providing informed consent for medical procedures and will need to be notified if there is a medical emergency or problem.

Discharge Documents

It is important that the appropriate person sign the documents indicated below.

  • Discharge Plan: Prior to discharge, the hospital staff, usually the nurse, reviews the discharge plan with the patient and caregiver. After reviewing the plan, the patient or legal representative is asked to sign it, indicating they understand the plan.
  • AMA Discharge Form: If at any time, a patient chooses to leave the hospital prior to receiving the treatment ordered by the physician, the hospital requires that a discharge form be signed. This form states that the patient left the hospital Against Medical Advice (AMA) and the hospital is not liable.
  • Informed Consent: If a physician recommends a specific procedure, surgery or treatment be performed on the patient, the doctor is required to provide specific information to ensure that the patient understands the procedure, its risks and benefits and that he or she is providing informed consent. A form must be signed to document that consent was given.

Financial Documents

  • If the patient is capable of understanding the documents, and there is no legal decision maker (power of attorney or guardian of property) to sign, the patient is the appropriate person.
  • If the patient is not capable of understanding the documents, and there is a formal arrangement for decision-making (power of attorney or guardian of property), then the power of attorney or guardian of property should sign the documents.
  • If the participant is not capable of understanding the documents and there is no power of attorney or guardian of property, the surrogate decision maker under Maryland law may be asked to sign the documents.

Documents Related to Care or Treatment

  • If there is a guardian of the person, that individual should sign the documents.
  • If there is no guardian of the person, the patient should sign if he or she is capable of understanding the documents. If not, the surrogate decision maker identified under Maryland law may be asked to sign.

For information about wills, estates and probate or to learn how to register a will, the Maryland Register of Wills offers information and links to local registers.