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New Hampshire Advance Directive Form

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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.

Table of Contents


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

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Healthy NH

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New Hampshire Health Care Assoc.

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WellSense.org Version

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How to Write

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Step 1 – Durable Power of Attorney for Health Care – Enter the following in the lines provided:

  • Declarant’s Name
  • Date of Birth
  • Appoint the agent in charge of your health care- Provide the Agent’s name
  • Enter the Agent’s complete address and telephone number with area code

If you would like to have more than one agent, they will be in charge according to how they are listed on your form:

  • Enter the name of your second choice for agent
  • Provide your 2nd agent’s complete address and telephone number with area code

Step 3 –  The Declarant, must carefully read the statement provided and then move on to

Step 4 – Life-Sustaining Treatment – The Declarant must read the following sections. In each there are two health decision options;

  • Declarant must select either a. or b. in each section

Step 5 – Medically Administered Nutrition and Hydration – The Declarant must carefully review the information in this section and then:

  • Declarant must choose a. or b. – if not, the agent will have no right to stop complete withdrawal of nutrition and hydration

Step 6 – Explaining your instructions in further detail – The Declarant may choose none, 1,2 or all 3 selections in this section.

  • If the Declarant has even more instruction, more specific, they may type or write the information into the lines provided in this section
  • If more pages are needed, continue on added sheets and attach them to the document.
  • Once complete, go back to the end of this section and provide Declarant’s printed name and date of birth
  • Provide the name of the institution or Doctor’s office where a copy of this will be kept as well as any other person’s who may have a copy of the document
  • Enter the date of the Declarant’s signature to this section in dd/mm/yyyy format
  • Enter the Declarant’s signature or the person authorized to sign for them

Step 7 – Witnesses -Witnesses must review the statement and then enter:

  • Witnesses Signatures respectively
  • Witnesses complete addresses

Step 7 – Notarization – Once the notary has witnessed the signatures, they will complete the form and acknowledge by affixing the state seal

Step 8 –  Living Will Section – Begin by dating this section in dd/mm/yyyy format

  • Enter the name of the Declarant
  • Declarant must read the statement  in the living will
  • At the end of the section, the declarant must make their selection by initialing a. or b. according to their preferences.
  • Declarant must read the remainder of the document, if in agreement and understanding
  • Date the section in dd/mm/yyyy format
  • The Declarant/Principal must then enter their complete signature

Step 9 – This living will must be witnessed by two unrelated witnesses –

  • The witnesses must review the brief statement, if in agreement
  • Both witnesses must enter their following information respectively
  • Witness Signature
  • Complete Witness address
  • OR
  • If a notary or Justice of the peace will be completing the form, they will complete the remainder of the form and acknowledge with their state seal

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