New Jersey Medical Power of Attorney
This New Jersey Medical Power of Attorney is created in accordance with the New Jersey Advance Directives for Health Care Act, N.J.S.A. 26:2H-53 et seq., which allows individuals to appoint someone (an "Agent") to make health care decisions on their behalf should they become unable to do so themselves.
Notice: This document has significant and personal implications. Before signing, one should understand its content fully and carefully consider what health care decisions are being delegated to the Agent. It is advisable to discuss your wishes with the appointed Agent to ensure they understand and are willing and able to act on your behalf.
Part 1: Designation of Health Care Representative
I, _______________ (Name of Principal), residing at _______________ (Principal's Address), being of sound mind, hereby appoint:
Name of Agent: _______________
Address of Agent: _______________
Phone Number of Agent: _______________
as my Health Care Representative to make any and all health care decisions for me, except to the extent that I state otherwise in this document.
This Medical Power of Attorney becomes effective when I am unable to make or communicate health care decisions on my own, as determined by a physician.
Part 2: Limits on the Health Care Representative's Authority
You can grant your Health Care Representative as much or as little power as you wish. If you want to limit the powers you give to your Health Care Representative, describe those limits here:
__________________________________________________________
__________________________________________________________
If you have specific wishes about your health care, you may state them here or you may use a separate Living Will/Advance Directive to detail them:
__________________________________________________________
__________________________________________________________
Part 3: Special Provisions and Limitations
Notice: The following items are optional. If you agree with an item, write "Yes" next to it; if you disagree, write "No". If you do not include an answer, it will be assumed that you do not want to impose that condition on your Agent's authority.
- I want artificial nutrition and hydration to be provided in all situations: ___
- I do not want my life to be prolonged if I am pregnant and life support would allow the pregnancy to continue to live birth: ___
- I want to donate my organs upon death: ___
- I do not want to be treated in a nursing home: ___
Part 4: Signature and Acknowledgment
This document revokes any prior Medical Power of Attorney unless stated otherwise.
Signature of Principal: _____________________ Date: ____________
This document must be signed by the Principal in the presence of two (2) adult witnesses, neither of whom:
- Is related to the Principal by blood, marriage, or adoption,
- Is entitled to any portion of the estate of the Principal under any will or codicil of the deceased principal existing at the time of execution of this document or by operation of law then existing,
- Has a claim against any portion of the estate of the principal at the time of the execution of this document,
- Has direct financial responsibility for the Principal's medical care,
- Is a health care provider who is serving the Principal at the time of execution,
- Is an employee of a health care provider who is serving the Principal,
- Is the appointed Agent.
Witness 1 Signature: _____________________ Date: ____________
Witness 1 Name (Print): _____________________
Witness 2 Signature: _____________________ Date: ____________
Witness 2 Name (Print): _____________________
By my signature, I indicate that the Principal appears to be of sound mind and free from duress at the time of signing this document, and that I am not disqualified from serving as a witness.