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New Hampshire __________, 20 ___, by _____________________________________ ______________________________________ Notary Public/Justice of the Peace My Commission Expires: -5- __________________________ Address: ______________________________________ -4- STATE OF NEW HAMPSHIRE COUNTY OF __________ The foregoing instrument was acknowledged before me this __________ day of tness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: _________lth care is signed and that the principal has affirmed that he or she is aware of the nature of the document and is signing it freely and voluntarily. _____________________________________________ (Widay of ___, 20___ __________________________________________ (Signature) I declare that the principal appears to be of sound mind and free from duress at the time the durable power of attorney for hea_____________________________________________________ ______________________________________________________________________________ In witness whereof, I have hereunto signed my name this __________ ____________________________ and the following persons and institutions will have signed copies: _____________________________________________________________________________ _________________________th a disclosure statement explaining the effect of this document. I have read and understand the information contained in the disclosure statement. The original of this document will be kept at ______ act as my health care agent, I hereby appoint ____________________________________________ of ___________________________________ as alternate agent. I hereby acknowledge that I have been provided wi___________________________________________________________________ (attach additional pages as necessary) In the event the person I appoint above is unable, unwilling or unavailable, or ineligible to______________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ -3- ______________________________________________________________________________ ________________________________________________out refusing any specific types of treatment that are inconsistent with your religious beliefs or unacceptable to you for any other reason. You may leave this question blank if you desire. ___________ion and hydration.) 4. Here you may include any specific desires or limitations you deem appropriate, such as when or what life-sustaining treatment you would want used or withheld, or instructions abtreatment be withdrawn, artificial nutrition and hydration continue to be given to me. (If you fail to complete item 3, your agent will not have the power to direct the withdrawal of artificial nutritice of (a) or (b) and initial beside it): _______ (a) artificial nutrition and hydration not to be started or, if started, be discontinued, -or________ (b) although all other forms of life-sustaining (artificial nutrition and hydration). In carrying out any instructions I have given above in #1 or #2 or any instructions I may write in #4 below, I authorize my agent to direct that (circle your chochoice and initial beneath it.). (YES) _____________ (NO) ________________ 3. I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial feeding) _____________ (NO) ________________ 2. Whether terminally ill or not, if I become permanently unconscious I authorize my agent to direct that life-sustaining treatment be discontinued (Circle your lth care decisions, and if I am also suffering from a terminal illness, I authorize my agent to direct that life-sustaining treatment be discontinued (Circle your choice and initial beneath it.). (YESou may indicate your agreement or disagreement with any of the following statements and give your agent power to act in those specific circumstances. 1. If I become permanently incompetent to make heacal devices, drugs to maintain blood pressure, blood transfusions, and antibiotics.) There is also a section which allows you to set forth specific directions for these or other matters. If you wish yithout which a person would die, such as but not limited to the following: cardiopulmonary resuscitation, mechanical respiration, kidney dialysis or the use of other external mechanical and technologienience in expressing your wishes, some general statements concerning the withholding or removal of life-sustaining treatment are set forth below. (Life-sustaining treatment is defined as procedures wcare shall take effect in the event I become unable to make my own health care decisions. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS REGARDING HEALTH CARE DECISIONS. -2- For your conv______________ as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document or as prohibited by law. This durable power of attorney for health ES MAY BE YOUR HEALTH OR RESIDENTIAL CARE PROVIDER OR ONE OF THEIR EMPLOYEES. POWER OF ATTORNEY I, ___________________________________, hereby appoint ___________________________ of __________________OLLOWING PERSONS MAY NOT ACT AS WITNESSES: --the person you have designated as your agent; --your spouse; --your lawful heirs or beneficiaries named in your will or a deed; ONLY ONE OF THE TWO WITNESSor you. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO (2) OR MORE QUALIFIED WITNESSES WHO MUST BOTH BE PRESENT WHEN YOU SIGN AND ACKNOWLEDGE YOUR SIGNATURE. THE Fagent in the event that your agent is unwilling, unable, unavailable, or ineligible to act as your agent. Any alternate agent you designate will have the same authority to make health care decisions frovider orally or in writing. This document may not be changed or modified. If you want to make changes in the document you must make an entirely new one. You should consider designating an alternate u are able to do so, and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing him or her or your health care pnt will not be liable for health care decisions made in good faith on your behalf. Even after you have signed this document, you have the right to make health care decisions for yourself as long as yohould discuss this document with your agent and your physician and give each a signed copy. You should indicate on the document itself the people and institutions who will have signed copies. Your agehealth or residential care provider; the law does not permit a person to do both at the same time. You should inform the person you appoint that you want him or her to be your health care agent. You ssician, or an -1- employee of a home health agency, hospital, nursing home, or residential care home, other than a relative), that person will have to choose between acting as your agent or as your yer to explain it to you. The person you appoint as agent should be someone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your phy these issues and can answer your questions. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawsign it to make sure that you understand the nature and range of decisions which may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgable about decisions about your health care as you would have had if made consistent with state law. It is important that you discuss this document with your physician or other health care providers before you ou to eat and drink normally. Your agent will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent will have the same authority to makeof nutrition and fluids, your document must say so. Otherwise, your agent will not be able to direct that. Under no conditions will your agent be able to direct the withholding of food and drink for yeligible to be your agent. You may attach additional pages if you need more space to complete your statement. If you want to give your agent authority to withhold or withdraw the artificial providing rtification that you lack capacity, you must say so in the document and name a person to be able to certify your lack of capacity. That person may not be your agent or alternate agent or any person inegin when your doctor certifies that you lack the capacity to make health care decisions. If for moral or religious reasons you do not wish to be treated by a doctor or examined by a doctor for the ce cannot be alleviated by medication. You may state in this document any treatment you do not desire, except as stated above, or treatment you want to be sure you receive. Your agent's authority will bpregnant and if the withdrawal of that treatment is deemed likely to terminate the pregnancy unless the failure to withhold the treatment will be physically harmful to you or prolong severe pain whichithdrawing or withholding life-sustaining treatment. Your agent cannot consent or direct any of the following: commitment to a state institution, sterilization, or termination of treatment if you are therefore, can have the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about w for you when you are no longer capable of making them yourself. "Health care'' means any treatment, service or procedure to maintain, diagnose or treat your physical or mental condition. Your agent, DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS: Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisionsound at findlegalforms.com -3- Durable Power Of Attorney For Health Care INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY FOR HEALTH CARE THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use f using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with anothergal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for lerincipal's residential care provider. IV. A nonrelative of the principal who is an employee of the principal's residential care provider. [_] These forms are provided "as is" and no implied or expressent while serving in one of the following capacities: I. The principal's health care provider. II. A nonrelative of the principal who is an employee of the principal's health care provider. III. The py a durable power of attorney for health care shall be in substantially the following form (see form below): 137-J:4 Restrictions on Who May Act as Agent. A person may not exercise the authority of ag Form The durable power of attorney shall be in substantially the following form (see form below): 137-J:14 Durable Power of Attorney; Disclosure Statement The disclosure statement which must accompanof attorney for health care may be signed by the principal's name written by some other person in the principal's presence and at the principal's express direction. 137-J:15 Durable Power of Attorney; was -2- signed and that the principal affirmed that he was aware of the nature of the document and signed it freely and voluntarily. If the principal is physically unable to sign, the durable power ntial care provider or such provider's employee. The witness shall affirm that the principal appeared to be of sound mind and free from duress at the time the durable power of attorney for health careipal upon death of the principal under a will, trust or other testamentary instrument or deed in existence or by operation of law. No more than one such witness may be the principal's health or reside presence of 2 or more subscribing witnesses, neither of whom shall, at the time of execution, be the agent, the principal's spouse or heir, or a person entitled to any part of the estate of the princall inform the principal's health or residential care provider of such revocation. 137-J:5 Execution and Witnesses The durable power of attorney for health care shall be signed by the principal in thetion in the principal's medical record and notify the agent, the attending physician, and staff responsible for the principal's care of the revocation. An agent who becomes aware of such revocation shr of attorney. II. A principal's health or residential care provider who is informed of or provided with a revocation of a durable power of attorney for health care shall immediately record the revoca. Re-execution or re-affirmation of the durable power of attorney for health care following filing for divorce shall make effective the designation of the former spouse as agent under the durable powee spouse is the principal's agent, except when there is an alternate agent designated, in which case the designation of the spouse shall be revoked and the alternate designation shall become effectivent to revoke the power; (b) By execution by the principal of a subsequent durable power of attorney for health care; or (c) By the filing of an action for divorce of the principal and spouse, where they for health care shall be revoked: (a) By notification by the principal to the agent or to a health or residential care provider orally, or in writing, or by any other act evidencing a specific intement and live birth of the unborn child or will be physically harmful to the patient or prolong severe pain which cannot be alleviated by medication. 137-J:6 Revocation. ­ I. A durable power of attornatient's chart by the attending physician and an obstetrician who has examined the patient, such treatment or procedures will not maintain the patient in such a way as to permit the continuing develop To consent to a voluntary sterilization; or (c) To consent to withholding life-sustaining treatment from a pregnant patient, unless, to a reasonable degree of medical certainty, as certified on the pr of any proposal to withdraw or withhold treatment. V. Nothing in this chapter shall be construed to give an agent authority: -1- (a) To consent to voluntary admission to any state institution; (b)ay not be given to or withheld from the principal over the principal's objection. The principal's attending physician shall make reasonable efforts to inform the principal of any proposed treatment, othe agent. IV. Notwithstanding that a durable power of attorney for health care is in effect and irrespective of the principal's lack of capacity to make health care decisions at the time, treatment mwledged before a notary or justice of the peace, as to the lack of decisional capacity of the principal. The person so designated by the principal shall not be the agent, or a person ineligible to be ious or moral beliefs as specified in the durable power of attorney for health care, a person designated by the principal in the durable power of attorney for health care may certify in writing, acknot shall be noted in the principal's medical record. A durable power of attorney for health care may include a provision that, if the principal has no attending physician for reasons based on his religalth care decisions, as certified in writing by the principal's attending physician and filed in the principal's medical record. When and if a person regains capacity to make such decisions, such evensts and in accordance with accepted medical practice. III. Under a durable power of attorney for health care, the agent's authority shall be in effect only when the principal lacks capacity to make hecare or in a terminal care document executed pursuant to the provisions of RSA 137-H; or if the principal's wishes are unknown, in accordance with the agent's assessment of the principal's best intereent's knowledge of the principal's wishes and religious or moral beliefs, as stated orally or otherwise communicated by principal to agent, or as contained in the durable power of attorney for health ncipal's behalf that the principal could make. II. After consultation with the attending physician and other health care providers, the agent shall make health care decisions in accordance with the agchapter and any express limitations set forth by the principal in the durable power of attorney for health care, the agent shall have the authority to make any and all health care decisions on the priare useful excerpts from the New Hampshire Statutes relating to the New Hampshire Power of Attorney for Health Care Form. 137-J:2 Scope and Duration of Authority. I. Subject to the provisions of this e Power of Attorney for Health Care Form. This New Hampshire Power of Attorney for Health Care is based on Title X Chapter 137-J Section 137-J:15 et. Seq. of the New Hampshire Statutes. The following Information and Instructions New Hampshire Power of Attorney for Health Care This package contains (1) Information and Instruction for New Hampshire Power of Attorney for Health Care; (2) New Hampshir New Hampshire