$17.95

Add to cart

New Jersey _____________________ Signature of (check one): _____Notary Public _____ Attorney at Law -3- , (name of declarant) whom I know to be such person, and the declarant did then and there execute this declaration. Sworn before me this ___________day of _________________, 20 ______. _______________ -2- Address: ______________________________________ Date: _______________________________________ OR Option 2: Notary Public On __________________, (date) before me came ________________________________________________________________ Date: _______________________________________ _____________________________________________ (Witness 2 Signature) Print Name: __________________________________rson's health care representative or alternate health care representative. _____________________________________________ (Witness 1 Signature) Print Name: ___________________________________ Address: ersonally known to me and that he or she appears to be of sound mind and free of duress or undue influence. I am 18 years of age or older, and am not designated by this or any other document as the peses or (2) notarized. Option 1: Two Witnesses I declare that the person who signed this document or asked another to sign this document on his or her behalf, did so in my presence, that he or she is p___________________________________________________________ Address: _________________________________________________________________ This document must be (1) witnessed by two qualified adult witnes wishes. I understand the purpose and effect of this document and sign it knowingly, voluntarily and after careful deliberation. Signed this _____ day of ___________________ 20 _____. Signature: _____ this designation with my health care representative(s) and my representative(s) has/have willingly agreed to accept the responsibility for acting on my behalf in accordance with this directive and myrective, I inform those who may become responsible for my health care of my wishes and intend to ease the burdens of decision making which this responsibility may impose. I have discussed the terms ofive (optional): ______________________________________________________________________________ ______________________________________________________________________________ By writing this advance di____________________________________________ -1- I direct that my health care representative comply with the following instructions in the event that I am pregnant when this Directive becomes effecte representative comply with the following instructions and/or limitations (optional): ______________________________________________________________________________ __________________________________Agent: __________________________________ __________________________________________________________ (Insert name, address, and telephone number of second alternate agent.) I direct that my health carrnate Agent: ____________________________________ _________________________________________________________ (Insert name, address, and telephone number of first alternate agent.) (B) Second Alternate I designate and appoint the following persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below: (A) First Altee decision for me or loses the mental capacity to make health care decisions for me, or if I revoke that person's appointment or authority to act as my agent to make health care decisions for me, thenntative is authorized to make decisions in my best interests. If the person designated as my agent in the first paragraph is not available or becomes ineligible to act as my agent to make a health carnforming my family or next of kin of my desire, if any, to be an organ or tissue donor. In the event my wishes are not clear, or if a situation arises that I did not anticipate, my health care represe document or otherwise made known to my agent, including, but not limited to, my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures and ihat I could make such decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in thisan individual's physical or mental condition. Subject to any limitations in this document, I hereby grant to my agent full power and authority to make health care decisions for me to the same extent tnt. For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat ress, and telephone number of one individual only as your agent to make health care decisions for you). as my attorney in fact (agent) to make health care decisions for me as authorized in this documettorney for Health Care I, ________________________________________________ (insert your name and address) do hereby designate and appoint: __________________________________________ (insert name, addng 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 found at findlegalforms.com -3- Power of Ahave an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arisito 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 using or signing this document you should 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 legal and/or tax advice. Laws vary from time y be determined, shall make a health care decision in the best interests of the patient. -2- [_] These forms are provided "as is" and no implied or express warranties have been made or are provided representative shall seek to make the health care decision the patient would have made had he possessed decision making capacity under the circumstances, or, when the patient's wishes cannot adequatelthe patient's medical condition, prognosis and treatment options, and to give informed consent to, or refusal of, health care. f. In the exercise of these rights and responsibilities, the health care health care representative or as an alternate health care representative may decline to serve in that capacity. e. The health care representative shall exercise the patient's right to be informed of ty on the health care representative shall not be construed to impose liability upon the health care representative for any portion of the patient's health care costs. d. An individual designated as al authority to make health care decisions on the patient's behalf, unless the terms of the legal guardian's court appointment or other court decree provide otherwise. c. The conferral of legal authorinds of the authority granted by the advance directive and by this act. b. If a different individual has been appointed as the patient's legal guardian, the health care representative shall retain legaion making capacity, a health care representative shall have authority to make health care decisions on behalf of the patient. The health care representative shall act in good faith and within the bousks of, and alternatives to, the proposed health care, and to reach an informed decision. 26:2H-61. Authority to make health care decisions 9. a. If it has been determined that the patient lacks decisbased upon, but need not be limited to, evaluation of the patient's ability to understand and appreciate the nature and consequences of a particular health care decision, including the benefits and rie construed as a determination of a patient's incapacity or incompetence for any other purpose. g. For purposes of this section, a determination that a patient lacks decision making capacity shall be rds. f. A determination of lack of decision making capacity under this act is solely for the purpose of implementing an advance directive in accordance with the provisions of this act, and shall not blution process established by the health care institution pursuant to section 14 of this act. Notice to the patient and the health care representative shall be documented in the patient's medical recoeen determined to lack decision making capacity to make a particular health care decision; (2) each has the right to -1- contest this determination; and (3) each may have recourse to the dispute resocian shall inform the patient, if the patient has any ability to comprehend that he has been determined to lack decision making capacity, and the health care representative that: (1) the patient has b. d. A physician designated by the patient's advance directive as a health care representative shall not make or confirm the determination of a lack of decision making capacity. e. The attending physialized training or experience. The opinion of the confirming physician shall be stated in writing and made a part of the patient's medical records in the same manner as that of the attending physicianogical conditions or developmental disabilities of the same or similar nature, a determination of a lack of decision making capacity shall be confirmed by one or more physicians with appropriate specimental or psychological impairment or a developmental disability, and neither the attending physician or the confirming physician has specialized training or experience in diagnosing mental or psychol the health care representative agree that confirmation is unnecessary. c. If the attending physician or the confirming physician determines that a patient lacks decision making capacity because of a of the attending physician. Confirmation of a lack of decision making capacity is not required when the patient's lack of decision making capacity is clearly apparent, and the attending physician andng capacity shall be confirmed by one or more physicians. The opinion of the confirming physician shall be stated in writing and made a part of the patient's medical records in the same manner as thatture, cause, extent, and probable duration of the patient's incapacity, and shall be made a part of the patient's medical records. b. The attending physician's determination of a lack of decision maki determine whether the patient lacks capacity to make a particular health care decision. The determination shall be stated in writing, shall include the attending physician's opinion concerning the na New Jersey Statutes relating to the New Jersey Power of Attorney for Health Care Form. 26:2H-60. Determination of patient's capacity to make a health care decision 8. a. The attending physician shallf Attorney for Health Care Form. This New Jersey Power of Attorney for Health Care is based on Title 26 Section 26:2H-60 et. Seq. of the New Jersey Statutes. The following are useful excerpts from theInformation and Instructions New Jersey Power of Attorney for Health Care This package contains (1) Information and Instruction for New Jersey Power of Attorney for Health Care; (2) New Jersey Power o New Jersey