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New Mexico itness Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ 5 Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ ____________________________________________ (Second W_____________________________________ Social Security Number: _________________________ (Optional) SIGNATURES OF WITNESSES: 4 _____________________________________________ (First Witness Signature): Sign and date the form here: Date: _____________________________________ __________________________________________ (Declarant's Signature) Print Name: ___________________________________ Address: _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. (10) SIGNATURESECTIVE 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 ______________________________ (phone) (8) EFFECT OF COPY: A copy of this form has the same effect as the original. (9) REVOCATION: I understand that I may revoke this OPTIONAL ADVANCE HEALTHCARE DIR_________________ (name of physician) _____________________________________________________________________________ (address) (city) (state) (zip code) _______________________________________________e is not willing, able or reasonably available to act as my primary physician, I designate the following physician as my primary physician: ________________________________________________________________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (phone) If the physician I have designated abovsignate the following physician as my primary physician: 3 _____________________________________________________________________________ (name of physician) ____________________________________________________________________________________________ ______________________________________________________________________________ (Add additional sheets if needed.) PART 2 PRIMARY PHYSICIAN (7) I designated. (6) OTHER WISHES: (If you wish to 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: ___________________________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 whom I have named, in the order dest. 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 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 determines to be in my best interet 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 give in Part 2 of this form and myher 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-care decisions for me takes effec__________________________________________ (Add additional sheets if needed.) (3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician and one otdration and all other forms of health care to keep me alive, except as I state here: ______________________________________________________________________________ ____________________________________rized 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, hy______________ (address) (city) (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) 2 (2) AGENT'S AUTHORITY: My agent is autho _____________________________________________________________________________ (name of individual you choose as second alternate agent) _______________________________________________________________ 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 alternate agent:__________________________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) me, I designate as my first alternate agent: _____________________________________________________________________________ (name of individual you choose as first alternate agent) ________________________________________________________________ (home phone) (work phone) 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___________ (name of individual you choose as agent) _____________________________________________________________________________ (address) (city) (state) (zip code) ________________________________RNEY FOR HEALTH CARE (1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health-care decisions for me: __________________________________________________________________hat 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 at any time. PART 1 POWER OF ATTOders you may have, to any 1 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 have named as agent to make sure t 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 physician, to any other health-care proviation and all other forms of health care. PART 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 atrove or disapprove diagnostic tests, surgical procedures, programs of medication and orders not to resuscitate; and (d) direct the provision, withholding or withdrawal of artificial nutrition and hydre consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition; (b) select or discharge health-care providers and institutions; (c) appf you wish to rely on your agent for all health-care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to: (a) consent or refusthe authority of your agent, your agent may make all health-care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent ile to make decisions for you. Unless related to you, your agent may not be an owner, operator or employee of a health-care institution at which you are receiving care. Unless the form you sign limits someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably availab form is a power of attorney for health care. PART 1 lets you name another individual as agent to make health-care decisions for you if you become incapable of making your own decisions or if you want 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 form. If you use this form, be sure to sign it and date it. PART 1 of thislse to make health-care decisions for you. It also lets you express your wishes regarding the designation of your primary physician. THIS FORM IS OPTIONAL. Each paragraph and word of this form is alsoRE Explanation You have the right to give instructions about your own health care. You also have the right to name someone else to make health-care decisions for you. This form lets you name someone eocument 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 POWER OF ATTORNEY FOR HEALTH CA first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this dte for legal 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 or signed without consulting an attorneyr express 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 substitu directive, revocation of an advance health-care directive or designation or disqualification of a surrogate has the same effect as the original. [_] These forms are provided "as is" and no implied oghts as the patient to request, receive, examine, copy and consent to the disclosure of medical or any other health-care information. 24-7A-12. Effect of copy. A copy of a written advance health-careinformation. Information & Instructions ­ Page 3 Unless otherwise specified in an advance health-care directive, a person the n authorized to make health-care decisions for a patient has the same rict of this or any other writing used to create an advance health-care directive. An individual may complete or modify all or any part of the following form (see below for form): 24-7A-8. Health-care m. The following form may, but need not, be used to create an advance health-care directive. The other sections of the Uniform Health-Care Decisions Act [24-7A-1 to 24-7A-17 NMSA 1978] govern the effer legal separation. E. An advance health-care directive that conflicts with an earlier advance health-care directive revokes the earlier directive to the extent of the conflict. 24-7A-4. Optional for, by a nullification of the divorce, annulment or legal separation or by the dismissal or withdrawal, with the individual's consent, of a petition seeking annulment, divorce, dissolution of marriage oagent unless otherwise specified in the decree or in a power of attorney for health care. A designation revoked solely by this subsection is revived by the individual's remarriage to the former spouseon at which the patient is receiving care. D. The filing of a petition for or a decree of annulment, divorce, dissolution of marriage or legal separation revokes a previous designation of a spouse as re provider, agent, guardian or surrogate who is informed of a revocation shall promptly communicate the fact of the revocation to the supervising health-care provider and to any health-care institutihaving capacity, may revoke all or part of an advance health-care directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke. C. A health-cavocation must be signed for the individual and be witnessed by two witnesses, each of whom has signed at the direction and in the presence of the individual and of each other. B. An individual, while l, while having capacity, may revoke the designation of an agent either by a signed writing or by personally informing the supervising health-care provider. If the individual cannot sign, a written reuctions ­ Page 2 G. A written advance health-care directive may include the individual's nomination of a guardian of the person. 24-7A-3. Revocation of advance health-care directive. A. An individuashall consider the principal's personal values to the extent known to the agent. F. A health-care decision made by an agent for a principal is effective without judicial approval. Information & Instrknown to the agent. Otherwise, the agent shall make the decision in accordance with the agent's determination of the principal's best interest. In determining the principal's best interest, the agent 1 NMSA 1978] of the Uniform Health-Care Decisions Act. E. An agent shall make a health-care decision in accordance with the principal's individual instructions, if any, and other wishes to the extent l lacks or has recovered capacity or that another condition exists that affects an individual instruction or the authority of an agent, shall be made according to the provisions of Section 11 [24-7A-1, and ceases to be effective upon a determination that the principal has recovered capacity. D. Unless otherwise specified in a written advance health-care directive, a determination that an individuaincipal is receiving care. C. Unless otherwise specified in a power of attorney for health care, the authority of an agent becomes effective only upon a determination that the principal lacks capacitywer may include individual instructions. Unless related to the principal by blood, marriage or adoption, an agent may not be an owner, operator or employee of a health-care institution at which the prstanding the principal's later incapacity under the Uniform Health-Care Decisions 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 po authorize the agent to make any health-care decision the principal could have made while having capacity. The power must be in writing and signed by the principal. The power remains in effect notwith The instruction may be limited to take effect only if a specified condition arises. B. An adult or emancipated minor, while having capacity, may execute a power of attorney for health care, which mayht to make his or her own health-care decisions and may give an individual instruction. The instruction may be oral or written; if oral, it must be made by personally informing a health-care provider.d useful excerpts from the New Mexico Statutes relating to Advance Health Care Directives. 24-7A-2. Advance health-care directives. A. An adult or emancipated minor, while having capacity, has the rigf Attorney for Health Care Form. This New Mexico Power of Attorney for Health Care is based in part on Chapter 24 Section 7A2 et. Seq. of the New Mexico Statutes. For your convenience, we have includeInformation and Instructions New Mexico Power of Attorney for Health Care This package contains (1) Information and Instruction for New Mexico Power of Attorney for Health Care; (2) New Mexico Power o New Mexico