New Mexico Medical Power of Attorney
This Medical Power of Attorney is a legal document that grants an individual (known as the "Agent") the authority to make healthcare decisions on behalf of another individual (known as the "Principal"), in accordance with the New Mexico Uniform Health-Care Decisions Act.
Principal Information
Name: ____________________________________________________
Address: __________________________________________________
City, State, Zip: ___________________________________________
Date of Birth: ______________________________________________
Social Security Number: _____________________________________
Agent Information
Name: ____________________________________________________
Relationship to Principal: ___________________________________
Primary Phone Number: ______________________________________
Alternate Phone Number: ____________________________________
Email Address: _____________________________________________
Alternate Agent Information (In the event the primary Agent is unable or unwilling to serve)
Name: ____________________________________________________
Relationship to Principal: ___________________________________
Primary Phone Number: ______________________________________
Alternate Phone Number: ____________________________________
Email Address: _____________________________________________
Authority of Agent
The Agent is authorized to make any and all health care decisions for the Principal that the Principal could make, subject to any limitations in this document. This authority includes, but is not limited to, the power to:
- Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
- Select or discharge health care providers and institutions.
- Approve or disapprove diagnostic tests, surgical procedures, and programs of medication.
- Decide on the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including ventilator support.
- Access medical records and information to the same extent that the Principal is entitled, including the right to disclose the contents to others.
Special Instructions (Optional)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Effective Date and Duration
This document shall become effective upon the incapacity of the Principal and shall remain in effect unless revoked by the Principal or until the Principal's death.
Signatures
This document must be signed and dated by the Principal, a witness, and the Agent to be legally valid.
Principal's Signature: ______________________________________ Date: _________________
Agent's Signature: _________________________________________ Date: _________________
Witness' Signature: _________________________________________ Date: _________________
State of New Mexico
County of ______________________
On this day of _________________, 20____, before me, a Notary Public in and for said State, personally appeared ____________________________________________________________________, known to me to be the Principal named in the New Mexico Medical Power of Attorney, and acknowledged to me that he/she executed the same for the purposes therein contained.
In Witness Whereof, I hereunto set my hand and official seal.
Notary Public: ____________________________________________
My commission expires: ____________________________________