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New Mexico ddress: ______________________________________ Date: _________________________________________ 4 _____________________________ Date: _________________________________________ _____________________________________________ (Second Witness Signature) Print Name: ___________________________________ A_________________________ (Optional) SIGNATURES OF WITNESSES: _____________________________________________ (First Witness Signature) Print Name: ___________________________________ Address: _____________________ __________________________________________ (Declarant's Signature) Print Name: ___________________________________ Address: ______________________________________ Social Security Number: oke the designation of an agent either by a signed writing or by personally informing the supervising health-care provider. (9) SIGNATURES: Sign and date the form here: Date: _________________________y 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 revECT OF COPY: A copy of this form has the same effect as the original. 3 (8) REVOCATION: I understand that I may revoke this OPTIONAL LIVING WILL at any time, and that if I revoke it, I should promptl____________________________________________________________________ (address) (city) (phone) (state) (zip code) _____________________________________________________________________________ (7) EFFto act as my primary physician, I designate the following physician as my primary physician: _____________________________________________________________________________ (name of physician) _________(city) (phone) (state) (zip code) _____________________________________________________________________________ If the physician I have designated above is not willing, able or reasonably available ry physician: _____________________________________________________________________________ (name of physician) _____________________________________________________________________________ (address) ________ ______________________________________________________________________________ (Add additional sheets if needed.) PART 2 PRIMARY PHYSICIAN (6) I designate the following physician as my prima write your own instructions, or if you wish to add to the instructions you have given above, you may do so here.) I direct that: ____________________________________________________________________________________________________________________________ 2 [ ] I REFUSE to make an anatomical gift of any of my organs or tissue. [ ] I CHOOSE to let my agent decide. (5) OTHER WISHES: (If you wish toatomical gift of some of my organs and tissue as specified below, and artificial support may be maintained long enough for organs to be removed. ______________________________________________________ ll 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. [ ] I CHOOSE to make a partial an(4) 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: [ ] I CHOOSE to make an anatomical gift of ained, even if this care hastens my death: ______________________________________________________________________________ ______________________________________________________________________________ xcept 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 maintal nutrition. [ ] I DO NOT want artificial hydration unless required for my comfort OR [ ] I DO want artificial hydration. (3) RELIEF FROM PAIN: Regardless of the choices I have made in this form and er me. (2) 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 artificiae within the limits of generally accepted health-care standards. [ ] I CHOOSE To Let My Agent Decide My agent under my power of attorney for health care may make life-sustaining treatment decisions foed below in one of the following three boxes: [ ] I CHOOSE NOT To Prolong Life I do not want my life to be prolonged. 1 [ ] I CHOOSE To Prolong Life I want my life to be prolonged as long as possiblnt 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 initialy 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 treatmeIONS FOR HEALTH CARE (1) 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 mion at which you are receiving care and to any health-care agents you may have named. You have the right to revoke this advance health-care directive or replace this form at any time. PART 1 INSTRUCThat you request two other individuals to sign as witnesses. Give a copy of the signed and completed form to your physician, to any other health-care providers you may have, to any health-care institutT 2 of this form lets you designate a physician to have primary responsibility for your health care. After completing this form, sign and date the form at the end. It is recommended but not required tther you want to make an anatomical gift of some or all of your organs and tissue. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. PARshes regarding life-sustaining treatment, including the provision of artificial nutrition and hydration, as well as the provision of pain relief. In addition, you may express your wishes regarding wheorm. If you use this form, be sure to sign it and date it. PART 1 of this form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wician. 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 free to use a different fo give instructions about your own health care. This form lets you to give instructions about your own health care. It also lets you express your wishes regarding the designation of your primary physid 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 LIVING WILL Explanation You have the right ton. Advice from a local attorney is always recommended when dealing with Information & Instructions ­ Page 3 estate planning matters. Any possible tax consequences arising out of this document shoul to time and from state to 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 situati 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 timeirective or designation or 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 providede health-care directive revokes the earlier directive to the extent of the conflict. 24-7A-12. Effect of copy. A copy of a written advance health-care directive, revocation of an advance health-care dhdrawal, 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 with an earlier advancesignation 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 the dismissal or witulment, 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 for health care. A dunicate 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 for or a decree of annesignation 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 revocation shall promptly comms 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 directive, other than the dr 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 witnesses, each of whom hamination 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 by a signed writing o-care decision made by an agent for a principal is effective without judicial approval. Information & Instructions ­ Page 2 G. A written advance health-care directive may include the individual's not'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 the agent. F. A healthdecision 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 accordance with the agenl 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 make a health-care 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 affects an individuaare, 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 recovered capacity.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 attorney for health c-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 principal by blood, marriage ving 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 Decisions Act [24-7Adult 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 could have made while hainstruction 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 condition arises. B. An a4-7A-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 individual instruction. The n part 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 Health Care Directives. 2Information and Instructions New Mexico Living Will This package contains (1) Information and Instruction for New Mexico Living Will; (2) New Mexico Living Will. This New Mexico Living Will is based i New Mexico