New Hampshire Medical Power of Attorney Form

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A New Hampshire medical power of attorney form allows a selected agent to wield a principal’s power and authority, per RSA 137-J, to make health care decisions on his or her behalf. Such an agent would wield principal authority if (or when) the principal cannot make decisions for him or herself. Thus, if you are in an accident or under anesthesia for surgery, or otherwise incapacitated, your preferred agent will already be set in place to make decisions on your behalf and in accordance with your preferences.

Laws

How to Write

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1 – Prepare To Report The Required Information.

This form will be available through the buttons on this page (bearing the labels “PDF,” “ODT,” and “Word”) in a file containing two forms. One or both may be filled out at the Principal’s discretion.

2 – Durable Power And Living Will Disclosure Statement.

Enter the Name of the Principal who is appointing the Power to make Health Care Decisions on his or her behalf on the first blank space of this document.

On the second blank space of the first paragraph, report the Full Name of the individual who will be granted the Authority to make Health Care Decisions on behalf of the Principal as a result of this document. Use the third blank space in this paragraph to enter the City and State where the Health Care Agent lives

The Principal may choose an Alternate Health Care Agent to assume the Authority granted through this document, if the Health Care Agent will no longer act as such (regardless of the reason). Locate the second paragraph in this document, then report the Name of the Alternate Health Care Agent as well as the City/State where he or she lives in the two blank spaces provided.

3 – Principal Instructions In Health Care

The First section, “Life-Sustaining Treatment,” focuses on the Principal’s wishes regarding medical treatment that is deemed necessary for the Principal to continue to live (i.e. dialysis). The Principal must choose the appropriate statement by initialing the blank space preceding it.

If the Principal does not wish Life-sustaining Treatment, then he or she must initial Choice (a). This means that if Life-sustaining Treatment is being administered, it must be discontinued.

If the Principal wishes Life-Sustaining Treatment to be administered, then he or she must initial Choice (b).

The Second Item requires a defined directive should the Principal become permanently unconscious. If the Principal does not wish any Life-Sustaining Treatment, then he or she must initial the blank space preceding Choice (a). If the Principal does wish to receive Life-sustaining Treatment when rendered permanently unconscious then, he or she should initial Choice (b).

Section B, “Medically Administered Nutrition and Hydration,” will seek to define the Principal’s wishes regarding medically administered Nutrition and Hydration when he or she requires such care to continue living. If the Principal does not wish medically administered Nutrition and Hydration to be administered or continued, he or she should initial Choice (a).  If the Principal does wish to have his or her Nutrition and Hydration needs met, even if medically administered, the Principal must initial Choice (b).

Section C has been provided so the Principal will have an opportunity to provide any Additional Instructions or Directives. If there is not enough room, this report may be continued in a separate document, attached, and cited in this section.

4 – Satisfying Form Requirements

Next, report where the original of this form is kept. This address should be reported on the blank space following the words “The original of this directive…”

Locate the term “Signed this.” The Principal must report the Date he or she is signing this document utilizing the blank spaces provided in this statement.

The Principal must Sign his or her name on the line labeled “Principal’s Signature.” This Signature must take place in front of Two Witnesses, a Notary Public, or a Justice of the Peace.

If this document will be verified by two individuals witnessing the signing, each witness will need to Sign his or her Name then supply his or her Residential Address.

If this document will be verified through Notarization, the section below the Principal/Witness Signature Lines will provide ample space with the appropriate language for a Notary Public.

Part II will be composed of a Living Will Form. If this will be tended to, make sure to enter the Date using the three spaces available on the first line.

5 – Principal Living Will Introduction

In the first paragraph, after the word “I,” the Principal’s Name must be presented on the blank line.

Next, the Principal must indicate his or her preference regarding Nutrition and Hydration as a Life-sustaining Treatment. Two choices have been provided for this purpose.The Principal should initial the blank space preceding Choice (a), if he or she does not authorize medically administered Nutrition or Hydration.The Principal should initial the blank space just before Choice (b) if he or she does authorize medically administered Nutrition or Hydration.

7 – Living Will Confirmation

The top of the next page will provide an area for the Principal Signature and an area to either verify the document by Witness or by Notary.

The Principal should report the Signature Date on the first line utilizing the spaces following the words “Signed this.”

Once the Signature Date has been reported, the Principal must sign his or her Name on the blank line labeled “Principal’s Signature.”

Below the Signature Area, the signing of this document may be authenticated by having each Witness sign his or her Name after the Testimonial then supply his or her Home Address.

If this signing is being notarized, the section beginning with the words “State of New Hampshire” has been provided for the use of the Notary Public.