Name Your Agent

Make sure they know who to call

Your health care agent makes medical decisions for you if you can't.

Supported by Howard County General Hospital and Maryland Hospital Association

Name Your Agent

Print and fill out this form.
(Available in English, Spanish, and Korean)


Scan it and save as a PDF.


Go to Create a username and password, then follow the 4 steps to upload your form.

Log in here if you have an account

Be sure to share your preferences with your health care agent.
See how to talk to your loved ones about your preferences for care.

Take me right to:

Get in-person help at an event

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Talk to loved ones about my preferences for care

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Reach out with questions

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