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New Mexico __________________ 6 __ ____________________________________________ (Second Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _______________________________________________________ (First Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _______________________________________ure) Print Name: ___________________________________ Address: ______________________________________ Social Security Number: _________________________ (Optional) SIGNATURES OF WITNESSES: _____________informing the supervising health-care provider. (14) SIGNATURES: Sign and date the form here: Date: _____________________________________ __________________________________________ (Declarant's Signat 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 derstand that I may revoke this OPTIONAL ADVANCE HEALTHCARE DIRECTIVE at any time, and that if I revoke it, I should promptly notify my supervising health-care provider and any health-care institution (state) (zip code) _____________________________________________________________________________ (12) EFFECT OF COPY: A copy of this form has the same effect as the original. (13) REVOCATION: I un_________________________________________________________________________ (name of physician) _____________________________________________________________________________ 5 (address) (city) (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: ____ of physician) _____________________________________________________________________________ (address) (city) (phone) (state) (zip code) ______________________________________________________________ional sheets if needed.) PART 3 PRIMARY PHYSICIAN (11) I designate the following physician as my primary physician: _____________________________________________________________________________ (namemay do so here.) I direct that: ______________________________________________________________________________ ______________________________________________________________________________ (Add additof any of my organs or tissue. [ ] I CHOOSE to let my agent decide. (10) OTHER WISHES: (If you wish to write your own instructions, or if you wish to add to the instructions you have given above, you maintained long enough for organs to be removed. ______________________________________________________ ______________________________________________________ [ ] I REFUSE to make an anatomical gift ial 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 and tissue as specified below, and artificial support may ben anatomical gift of all or some of my organs or tissue: [ ] 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 artific_____________________ ______________________________________________________________________________ (9) ANATOMICAL GIFT DESIGNATION: Upon my death I specify as marked below whether I choose to make aean, 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: _________________________________________________________ artificial hydration. (8) 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 clecify 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 wante My agent under my power of attorney for health care may make life-sustaining treatment decisions for me. (7) ARTIFICIAL NUTRITION AND HYDRATION: If I have chosen above NOT to prolong life, I also sp life to be prolonged. [ ] 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. [ ] I CHOOSE To Let My Agent Decid involved in my care provide, withhold or withdraw treatment in accordance with the choice I have initialed below in one of the following three boxes: [ ] I CHOOSE NOT To Prolong Life I do not want mye 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 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 degre 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. 3 (6) END-OF-LIFE DECISIONS: If I am unable to make or communicate decisionshom I have named, in the order designated. 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 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 alternate agents wetermines to be 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 personive 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 for me in accordance with what my agent dcare decisions for me takes effect immediately. (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 gn my primary physician and one other qualified health-care professional determine that I am unable to make my own health-care decisions. If I initial this box [ ], my agent's authority to make health-____________________________________________________________________________ (Add additional sheets if needed.) (3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective whe withdraw artificial nutrition, hydration and all other forms of health care to keep me alive, except as I state here: ______________________________________________________________________________ __ENT'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___________________________________________________ (address) (home phone) (city) (state) (zip code) (work phone) _____________________________________________________________________________ (2) AGate as my second alternate agent: 2 _____________________________________________________________________________ (name of individual you choose as second alternate agent) ________________________________ (home phone) (work phone) 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 designernate agent) _____________________________________________________________________________ (address) (city) (state) (zip code) _______________________________________________________________________o make a health-care decision for me, I designate as my first alternate agent: _____________________________________________________________________________ (name of individual you choose as first alt _____________________________________________________________________________ (home phone) (work phone) If I revoke my agent's authority or if my agent is not willing, able or reasonably available t____________________________________________ (name of individual you choose as agent) _____________________________________________________________________________ (address) (city) (state) (zip code) t any time. PART 1 POWER OF ATTORNEY FOR HEALTH CARE (1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health-care decisions for me: _________________________________ave named as agent to make sure that he or she understands your wishes and is willing to take the responsibility. You have the right to revoke this advance health-care directive or replace this form aician, to any other health-care providers you may have, to any health-care institution at which you are receiving care and to any health-care agents you have named. You should talk to the person you h this form, sign and date the form at the end. It is recommended but not required that you request two other individuals to sign as witnesses. Give a copy of the signed and completed form to your physto the choices you have made or for you to write out any additional wishes. 1 PART 3 of this form lets you designate a physician to have primary responsibility for your health care. After completingrovision of pain relief. In addition, you may express your wishes regarding whether you want to make an anatomical gift of some or all of your organs and tissue. Space is also provided for you to add any aspect of your health care. Choices are provided for you to express your wishes regarding life-sustaining treatment, including the provision of artificial nutrition and hydration, as well as the pcitate; and (d) direct the provision, withholding or withdrawal of artificial nutrition and hydration and all other forms of health care. PART 2 of this form lets you give specific instructions about cal or mental condition; (b) select or discharge health-care providers and institutions; (c) approve or disapprove diagnostic tests, surgical procedures, programs of medication and orders not to resusot to limit the authority of your agent, your agent will have the right to: (a) consent or refuse consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physie for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health-care decisions that may have to be made. If you choose ne of a health-care institution at which you are receiving care. Unless the form you sign limits the authority of your agent, your agent may make all health-care decisions for you. This form has a placn alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator or employeealth-care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name aee to use a different form. If you use this form, be sure to sign it and date it. PART 1 of this form is a power of attorney for health care. PART 1 lets you name another individual as agent to make hn of your primary physician. THIS FORM IS OPTIONAL. Each paragraph and word of this form is also optional. If you use this form, you may cross out, complete or modify all or any part of it. You are fr You also have the right to name someone else to make health-care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding the designatioof these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com ADVANCE HEALTH-CARE DIRECTIVE Explanation You have the right to give instructions about your own health care.orney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attr 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 to time and from state to disqualification of a surrogate has the same effect as the original. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability fosclosure of medical or any other health-care information. 24-7A-12. Effect of copy. A copy of a written advance health-care directive, revocation of an advance health-care directive or designation or ed in an advance health-care directive, a person then authorized to make health-care decisions for a patient has the same rights as the patient to request, receive, examine, copy and consent to the dictive. An individual may complete or modify all or any part of the following form (see below for form): 24-7A-8. Health-care information. Information & Instructions ­ Page 3 Unless otherwise specifith-care directive. The other sections of the Uniform Health-Care Decisions Act [24-7A-1 to 24-7A-17 NMSA 1978] govern the effect of this or any other writing used to create an advance health-care direth an earlier advance health-care directive revokes the earlier directive to the extent of the conflict. 24-7A-4. Optional form. The following form may, but need not, be used to create an advance healthe dismissal or withdrawal, with the individual's consent, of a petition seeking annulment, divorce, dissolution of marriage or legal separation. E. An advance health-care directive that conflicts wifor health care. A designation revoked solely by this subsection is revived by the individual's remarriage to the former spouse, by a nullification of the divorce, annulment or legal separation or by r or a decree of annulment, divorce, dissolution of marriage or legal separation revokes a previous designation of a spouse as agent unless otherwise specified in the decree or in a power of attorney shall promptly communicate the fact of the revocation to the supervising health-care provider and to any health-care institution at which the patient is receiving care. D. The filing of a petition fove, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke. C. A health-care provider, agent, guardian or surrogate who is informed of a revocationses, each of whom has signed at the direction and in the presence of the individual and of each other. B. An individual, while having capacity, may revoke all or part of an advance health-care directiy a signed writing or by personally informing the supervising health-care provider. If the individual cannot sign, a written revocation must be signed for the individual and be witnessed by two witnes the individual's nomination of a guardian of the person. 24-7A-3. Revocation of advance health-care directive. A. An individual, while having capacity, may revoke the designation of an agent either be agent. Information & Instructions ­ Page 2 F. A health-care decision made by an agent for a principal is effective without judicial approval. G. A written advance health-care directive may includerdance with the agent's determination of the principal's best interest. In determining the principal's best interest, the agent shall consider the principal's personal values to the extent known to th make a health-care decision in accordance with the principal's individual instructions, if any, and other wishes to the extent known to the agent. Otherwise, the agent shall make the decision in accoaffects an individual instruction or the authority of an agent, shall be made according to the provisions of Section 11 [24-7A-11 NMSA 1978] of the Uniform Health-Care Decisions Act. E. An agent shall recovered capacity. D. Unless otherwise specified in a written advance health-care directive, a determination that an individual lacks or has recovered capacity or that another condition exists that ttorney for health care, the authority of an agent becomes effective only upon a determination that the principal lacks capacity, and ceases to be effective upon a determination that the principal has by blood, marriage or adoption, an agent may not be an owner, operator or employee of a health-care institution at which the principal is receiving care. C. Unless otherwise specified in a power of aDecisions Act [24-7A-1 to 24-7A-17 NMSA 1978] or Article 5 of the Uniform Probate Code [Chapter 45, Article 5 NMSA 1978]. The power may include individual instructions. Unless related to the principald have made while having capacity. The power must be in writing and signed by the principal. The power remains in effect notwithstanding the principal's later incapacity under the Uniform Health-Care tion arises. B. An adult or emancipated minor, while having capacity, may execute a power of attorney for health care, which may authorize the agent to make any health-care decision the principal coulal instruction. The instruction may be oral or written; if oral, it must be made by personally informing a health-care provider. The instruction may be limited to take effect only if a specified condih Care Directives. 24-7A-2. Advance health-care directives. A. An adult or emancipated minor, while having capacity, has the right to make his or her own health-care decisions and may give an individu and Living Will) is based on Chapter 24 Section 7A-2 et. Seq. of the New Mexico Statutes. For your convenience, we have included useful excerpts from the New Mexico Statutes relating to Advance Healtare and Living Will); (2) New Mexico Advance Health Care Directive (Power of Attorney for Health Care and Living Will). This New Mexico Advance Health Care Directive (Power of Attorney for Health CareInformation and Instructions New Mexico Advance Health Care Directive This package contains (1) Information and Instruction for New Mexico Advance Health Care Directive (Power of Attorney for Health C New Mexico