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New Jersey Health Care Proxy Directive (Medical POA) Form

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The New Jersey Health Care Proxy Directive Form, also known as a ‘Durable Power Of Attorney For Health Care’ or ‘Advance Directive’, should be executed when one must appoint a Health Care Representative to make medical decisions on behalf of the issuer. This sort of paperwork will usually only come into play when the issuer or Principal suffers a traumatic medical event that severely limits his or her ability to communicate any decisions regarding medical treatment. Some information will be required of the Principal before he or she can set this appointment in motion. Each piece of information requested by this document is geared toward making sure the Principal’s wishes are clearly communicated and solidified. Thus, it is in his or her interest to reserve enough time to provide an accurate representation of any preferences or directives the Agent should follow when the Principal is incapacitated and a medical event requires decisions.

This document can provide peace of mind in knowing that someone you love and trust is there to make sure your wishes and best interests are being represented when you’ve been in an accident, are under anesthesia or are otherwise incapable of making decisions on your own.

Definition –  § 26:2H-55

Laws – § 26:2H-57

Advance Directive – Combines the Proxy Directive with a Living Will setting out the patient’s wishes for a surrogate and their end of life treatment options.

Living Will – Also known as the ‘instruction directive’ that gives an individual the option to either prolong their life or discontinue artificial ways to keep them alive if they should be in a place where there is no known remedy.

Durable Power of Attorney – A Durable (Financial) Power of Attorney is used to select a financial representative who will ensure your finances are handled according to your wishes.

How to Write

1 – Open This Form Utilizing One of the Buttons Beneath The Preview Image

Download the provided New Jersey proxy directive and review it carefully. If you have the information requested regarding the Principal, Principal’s Preferences, and Agent concerned, then open the form on this page using one of the image buttons.

2 – Principal And Agent Information Must Both Be Provided At The Start Of This Form

The Principal, and anyone involved, should read this form both before and after it has been completed. Section A shall call for the information completing a declaration statement to be supplied. Use the first blank space in Section A to present the Principal’s Full Name.

Look for the words “Hereby Designate,” then enter the Full Name of the Health Care Agent on the available space.

Now, after the word “of” fill in the Complete Address of the Agent. Make sure this is the Agent’s Home Address. Remember to include the Telephone Number as part of the Address (enter it after recording the Agent’s Zip Code).

3 – Fill In The Alternate Agent’s Name And Contact Information

An Alternate Agent is the individual who will act as the Health Care Agent if the individual named above cannot do so. There is enough room to designate two separate Alternate Health Care Agents however, this is not mandatory. Use the blank lines labeled “Name,” “Address,” “City,” “State,” and “Telephone” to declare each separate individuals as Alternate Health Care Agents. If there is only, only fill out the first column. If there are more, make sure to include an attachment with the Name, Address, City, State, and Telephone Number of each Alternate Health Care Agent. Only individuals named as a Health Care Agent (regardless of role) in this document will be permitted to act as such as a result of this document.

4 – The Directions Of The Principal Should Be Outlined

Find Section C. Here, the Principal will need to initial one of the first two statements before continuing. If the Principal wishes the Health Care Agent to have the Principal Power to have artificial Nutrition and Fluid withdrawn or withheld from the Principal’s Medical Treatment, he or she should initial the first statement. Otherwise, if the Health Care Agent should not have such Principal Power, the Principal should initial the second statement.

Directly below the statement choices will be a set of blank spaces. These should be used to report Principal Instructions, Directions, and/or Preferences that have not been covered by this form. If there is not enough room, you may continue the Principal Directions on an attachment.

5 – Disclose All Individuals Who Have Been Provided A Copy Of This Directive

Utilize the blank spaces labeled “Name,” “Address,” “City,” “State,” and “Telephone” to record the Identity and Contact Information of each individual the Principal has provided a copy of this Directive. There is enough room to report two individuals, however, if more copies have been made, continue the report on a separate document and attach it to this form.

6 – This Appointment And Directive May Only Be Finalized By Principal Signature

The statement “Signed This” must be tended to by the Principal when he or she is signing this document. The Principal must enter the Current Calendar Date when he or she signs this form using the three blank spaces in this statement.

Immediately below this, the Principal must sign the “Signature” line. The Principal must then, record the Address, City, and State where he or she lives.

Finally, each Witness who has watched the Principal Signing occur must read Section F, “Witnesses.” If this statement is true, each one must select one of the columns below this passage then sign his or her Name on the blank line labeled “Witness,” enter his or her “Address,” “City,” and “State.” Each Witness must use the last blank line in his or her column to enter the “Date” of his or her Signature.


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