Durable Power of Attorney for Health Care - New Mexico - Edit, Fill, Sign Online

1

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

I, _______________________, reside in ____________________ County, New Mexico:

(1) DESIGNATION OF AGENT: I designate the following individual as my agent to

make health-care decisions for me:

Name of Agent:

Agent’s Address:

Agent’s Telephone Number:

DESIGNATION OF SUCCESSOR AGENT(S)

(OPTIONAL)

If I revoke my agent's authority or if my agent is not willing, able or reasonably available

to make a health-care decision for me, I designate as my successor agent:

Name of Successor Agent:

Successor Agent’s Address:

Successor Agent’s Telephone Number:

If I revoke the authority of my agent and first alternate agent or if neither is willing, able

or reasonably available to make a health-care decision for me, I designate as my second

successor agent:

Name of Second Successor Agent: ________________________________________________

Second Successor Agent’s Address: _______________________________________________

Second Successor Agent’s Telephone Number: ______________________________________

2

(2) AGENT'S AUTHORITY: My agent is authorized to obtain and review medical

records, reports and information about me and to make all health-care decisions for me,

including decisions to provide, withhold or withdraw artificial nutrition, hydration and all other

forms of health care to keep me alive, except as I state here:

______________________________________________________________________________

My agent shall be entitled to all of my medical information and records as my personal

representative within the meaning of the Health Insurance Portability and Accountability Act.

(3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE:

Please initial either A or B:

(A)____________My agent's authority becomes effective immediately unless I have revoked the

agent’s authority.

(B) ____________My agent’s authority shall become effective only if I become incapacitated.

My agent shall be entitled to rely on notarized statements from two qualified health care

professionals as to my incapacity.

(4) AGENT'S OBLIGATION: My agent shall make health-care decisions for me in

accordance with this power of attorney for health care, any instructions I give in Part 2 of this

form and my other wishes to the extent known to my agent. To the extent my wishes are

unknown, my agent shall make health-care decisions which are in my best interest. In

determining my best interest, my agent shall consider my personal values to the extent known to

my agent.

(5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be

appointed for me by a court, I nominate the agent designated in this form. If that agent is not

willing, able or reasonably available to act as guardian, I nominate the successor agent whom I

have named, in the order designated.

(6) DURABILITY: This durable power of attorney for health care shall remain in

effect despite my later incapacity.

3

PART 2

INSTRUCTIONS FOR HEALTH CARE

If you are satisfied to allow your agent to determine what is best for you in making end-

of-life decisions, you need not fill out this part of the form. If you do fill out this part of the

form, you may cross out any wording you do not want.

(7) END-OF-LIFE DECISIONS: If I am unable to make or communicate decisions

regarding my health care, and IF (i) I have an incurable or irreversible condition that will result

in my death within a relatively short time, OR (ii) I become unconscious and, to a reasonable

degree of medical certainty, I will not regain consciousness, OR (iii) the likely risks and burdens

of treatment would outweigh the expected benefits, THEN I direct that my health-care providers

and others involved in my care provide, withhold or withdraw treatment in accordance with the

choice I have initialed below in one of the following two boxes:

[____________] (a) I CHOOSE NOT to Prolong Life

I do not want my life to be prolonged.

[____________] (b) I CHOOSE To Prolong Life

I want my life to be prolonged as long as possible within the limits

of generally accepted health-care standards.

(8) ARTIFICIAL NUTRITION AND HYDRATION: If I have chosen above NOT

to prolong life, I also specify by marking my initials below:

[____________] I DO NOT want artificial nutrition OR

[____________] I DO want artificial nutrition

[____________] I DO NOT want artificial hydration unless required for my comfort OR

[____________] I DO want artificial hydration.

(9) RELIEF FROM PAIN: Regardless of the choices I have made in this form and

except as I state in the following space, I direct that the best medical care possible to keep me

clean, comfortable and free of pain or discomfort be provided at all times so that my dignity is

maintained, even if this care hastens my death:

______________________________________________________________________________

(10) ANATOMICAL GIFT DESIGNATION: Upon my death I specify as marked

below whether I choose to make an anatomical gift of all or some of my organs or tissue:

Please Initial only one box

[____________] I CHOOSE to make an anatomical gift of all of my organs or tissue to be

determined by medical suitability at the time of death, and artificial

support may be maintained long enough for organs to be removed.

4

[____________] I CHOOSE to make a partial anatomical gift of some of my organs or

tissue as specified below, and artificial support may be maintained long

enough for organs to be removed. The following organs and tissue may be

donated:

_______________________________________________________

[____________] I REFUSE to make an anatomical gift of any of my organs or tissue.

[____________] I CHOOSE to let my agent decide.

(11) OTHER WISHES: (If you wish to write your own instructions for either health

care or end-of-life decisions, or if you wish to add to the instructions you have given above, you

may do so here.) I direct that:

______________________________________________________________________________

(Add additional sheets if needed. Sheets should be signed and dated.)

PART 3

PRIMARY PHYSICIAN

(12) I designate the following physician and/or facility as my primary physician:

______________________________________________________________________________

(name of physician)

______________________________________________________________________________

(address) (city) (state) (zip code)

______________________________________________________________________________

(phone)

If the physician I have designated above is not willing, able or reasonably available to act

as my primary physician, I designate the following physician as my primary physician:

______________________________________________________________________________

(name of physician)

______________________________________________________________________________

(address) (city) (state) (zip code)

______________________________________________________________________________

(phone)

5

(13) EFFECT OF COPY: A copy of this form has the same effect as the original

unless the original has been revoked.

(14) REVOCATION: I understand that I may revoke this OPTIONAL ADVANCE

HEALTH-CARE DIRECTIVE at any time, and that if I revoke it, I should promptly notify my

supervising health-care provider and any health-care institution where I am receiving care and

any others to whom I have given copies of this power of attorney. I understand that I may

revoke the designation of an agent either by a signed writing or by personally informing the

supervising health-care provider.

(15) SIGNATURES: Sign and date the form here:

SIGNATURE OF PERSON GIVING POWER OF ATTORNEY:

____________________________ ____________________________ _________________

Sign your name Print your name Date

Address (Street, City , State, Zip)

It is recommended, but not required, that this form be witnessed.

SIGNATURES OF WITNESSES:

First witness: Second witness:

____________________________________ ____________________________________

Sign your name Sign your name

____________________________________ ____________________________________

Print your name Print your name

____________________________________ ____________________________________

Date Date

_______________ __________________

Address Address

_______________________ __________________

City, State , Zip City, State, Zip

Revised 4/9/2008

Fillable Printable Durable Power of Attorney for Health Care - New Mexico

Fillable Printable Durable Power of Attorney for Health Care - New Mexico

Durable Power of Attorney for Health Care - New Mexico