New Hampshire Advance Directive Form

Create a high quality document online now!

A New Hampshire advance directive lets a person set up a durable power of attorney for health care and a living will. This allows someone to choose an agent to handle their health care needs, in case they cannot do so for themselves, and to outline their end-of-life care. This form is common to be completed by the elderly or individuals with health issues. The form becomes in effect after the person can no longer speak for themselves due to unconsciousness or incapacitation.

Advance Directive Includes

  • Section I. Durable Power of Attorney for Health Care
  • Section II. Living Will

Table of Contents

Laws

StatuteChapter 137-J (Written Directives for Medical Decision Making for Adults Without Capacity to Make Health Care Decisions)

Signing Requirements (§ 137-J:14) – Two (2) witnesses or a notary public.

State Definition – (§ 137-J:2(I)) – “Advance directive” means a directive allowing a person to give directions about future medical care or to designate another person to make medical decisions if he or she should lose the capacity to make health care decisions. The term “advance directives” shall include living wills and durable powers of attorney for health care.

Versions (4)


Core Physicians

Download: Adobe PDF

 

 

 


Healthy NH

Download: Adobe PDF

 

 

 


New Hampshire Health Care Assoc.

Download: Adobe PDF

 

 

 


WellSense.org Version

Download: Adobe PDF

 

 

 

How to Write

Download: Adobe PDF

Section I. Durable Power Of Attorney For Health Care

(1) Principal Name. The name of the New Hampshire Patient, who shall be considered the Principal or Declarant in this document, must be presented. For our goals, it shall be assumed the New Hampshire Patient or Principal is filling out this form personally.

(2) New Hampshire Principal Date Of Birth.

(3) Principal’s Choice Of Health Care Agent. This directive shall act as the instrument to grant the New Hampshire Attorney-in-Fact or Health Care Agent of your choice the power to represent your medical directives to Medical Professionals. For this power to be granted, you must record the name of the Party you have chosen for this task. It is strongly advised that the Party you designate with this authority is someone you trust to handle difficult treatment decisions that New Hampshire Doctors may require made while you are unconscious or incognizant.

(4) New Hampshire Health Care Agent’s Contact. Complete the area reserved for the address and the telephone number(s) of the New Hampshire Health Care Agent (Attorney-in-Fact).

(5) Successor New Hampshire Health Care Agent. If you become incapacitated or unable to make informed treatment decisions, then your New Hampshire Health Care Agent will be called upon to represent you. Since there is a possibility that your New Hampshire Health Care Agent cannot act, should not, or will not act in this role, a Successor Agent to inherit this role should be designated with the power to do so. Name the Party you wish to take over the responsibility of speaking with New Hampshire Doctors on your behalf should your first choice fail to assume this role.

A. Life-Sustaining Treatment

(6) Denying Life-Support When Terminal.  This document will request that you record the decisions you authorize your Agent to make on your behalf when you are near death. Initial Statement A to authorize your New Hampshire Agent to direct Medical Professionals in this state to cease any life-sustaining treatments when death is imminent.

(7) Approving Life-Support When Terminal. If you wish your New Hampshire Health Care Agent to authorize or even request life-sustaining treatment be administered when your death is near then initial Statement B.. 

(8) Denying Life-Support When Comatose. If you are in a permanent vegetative state, your body will eventually need to receive aid in certain functions necessary to sustain life. Your initials will be needed to approve of the New Hampshire Health Care Agent’s ability to deny life support from being administered or request that it is halted on your behalf. If you do not wish your Health Care Agent to direct New Hampshire Doctors to deny life-support when you are in a permanent vegetative state, then leave this statement unattended.

(9) Approving Life-Support When Comatose. You can set this document to approve your New Hampshire Health Care Agent’s authority to approve or request life-sustaining treatment administered when you are in a permanent vegetative state by initialing Statement B.

B. Medically Administered Nutrition And Hydration

(10) Denying Medical Administration Of Nutrients/Water. Regardless of whether you are near-death or in a permanent vegetative state, your body may become unable to intake food or water. For instance, if in a coma, even hand-assisted feedings present a significant choking hazard. If you wish your New Hampshire Agent to refuse nutrition and hydration delivered artificially (by means of a tube or an I.V.) then place your initials to the first statement in this section.

(11) Approving Medical Administration Of Nutrients/Water. If you wish to grant the New Hampshire Health Care Agent or Medical Attorney-in-Fact the ability to authorize Medical Professionals in this state to deliver your nutrients and water artificially when needed to prevent starvation and/or dehydration, then initial Statement B.

C. Explaining Your Instructions In More Detail

(12) Authority To Request DNR. To grant the New Hampshire Medical Attorney-in-Fact the power to issue a Do Not Resuscitate Order in your name, initial the first statement of Section C.

(13) Granting Full Principal Authority. To use this paperwork to designate the full authority a Medical Attorney-in-Fact or Health Care Agent can wield in this state on your behalf, place your initials to the second statement.

(14) Level Of New Hampshire Agent’s Authority. This directive can set the New Hampshire Medical Attorney-in-Fact’s authority over your medical care to supersede your own. This is often needed when a Patient suffers from severe neurological conditions such as dementia or schizophrenia. To grant this level of authority to the New Hampshire Attorney-in-Fact, initial the third statement in this area.

(15) Instructions And Principal Power Limitations. As the New Hampshire Principal or Patient, you can limit your Health Care Agent’s powers to represent you or supply direct instructions to him or her and Medical Professionals reviewing this paperwork. This can be immensely helpful when facing difficult questions. Supply your concerns, your directions, requests, and authorizations (at your discretion) to the area in the fourth statement.

(16) Identify This Page.

(17) Filing This Directive. It is generally recommended that a clear report on where the original directive will be stored as well as any copies made is included. Supply the location where this original will be stored then list every Party and location where a copy will be stored.

Signature

(18) New Hampshire Principal Signature Date.

(19) New Hampshire Principal Signature. To issue this paperwork, the New Hampshire Principal must sign this document while two Witnesses or a Notary Public watch this act. This signature must be produced on the same date that he or she reported as the signature date.

Witness Verification Option

(20) Witness Signature And Addresses. Two adult New Hampshire Witnesses willing to testify that you have signed this paperwork while cognizant and aware of your decision will be required to sign their names and present their addresses as proof that each one has watched you sign this directive in a clear state of mind.

Notary Public Option

(21) Signature Notarization. The option to use a Notary Public to prove the authenticity of your signature by subjecting it to the notarization process. Only a New Hampshire recognized Notary Public has the ability to complete the notarization area provided.

(22) Confirm The Third Page.

Section II Living Will

(23) Document Date. If you intend to issue direct instructions as to your medical treatment when you are near an end-of-life event, then continue to the second section where a report on the date of your directive should be documented.

(24) New Hampshire Declarant Name. Claim this section of the directive as your medical instructions by presenting your full name. If you are Preparing this document for the Person issuing it then furnish the full name of the Patient. For this section, it will be assumed that you are the New Hampshire Patient or Principal behind this paperwork.

(25) Medically Administered Nutrition And Hydration. Statement A or Statement B must be initialed. The first instructs New Hampshire Physicians to cease all attempts at medically delivered nutrition and/or hydration or to deny any future artificial administrations of nourishment/water when the end of life is near. To issue this instruction, initial the first statement otherwise, to inform New Hampshire Physicians that you wish to receive (if needed) nutrition and fluids even by tube, I.V., or other artificial means, then initial the second statement.

(26) Identify The Fourth Page.

(27) New Hampshire Signature And Signature Date. Sign your name after you have recorded the current date.

Witness Testimony

(28) Witness Signature And Address. If you have elected to sign this form before two Witnesses, then relinquish this signed document to each one. Both must provide a signature, and both must record their addresses.

Notary Public Or Justice Of The Peace Option

(29) Notary Public. If you have decided to have your signature notarized, then give this document to the notary after signing it (under his or her direction). The New Hampshire Notarial will then complete the notarization section then return this paperwork.

 

 

Related Forms


Durable (Financial) Power of Attorney

Download: Adobe PDF, MS Word, OpenDocument

 

 

 


Last Will and Testament

Download: Adobe PDF, MS Word, OpenDocument