New Hampshire Medical Power of Attorney Form

The New Hampshire medical power of attorney form is a document that contains both a Durable Health Care POA as well as a Living Will. The Principal may complete one or both documents. The document will provide written permission from the Principal for an Agent to act on their behalf in making decisions regarding their health care. These documents should be reviewed carefully before they complete and provide signatures. If once the document is reviewed and the Principal is not certain about the language provided, they may wish to speak with an attorney for clarification.

This document will ask that the Principal enter their wishes regarding their preference for their end of life arrangements. The Agent will be expected to consider all of the wishes of the Principal and act upon those wishes as if the Principal were of sound mind to make their own decisions.

This document must be signed before a licensed Notary. This document may be revoked at any time as the Principal chooses. In order to revoke the document, they will need to provide written notice, delivered to the Agent.

How to Write

Step 1 – Durable Powers for Health Care – Submit the following information –

  • Principal’s Name
  • Date of Birth in mm/dd/yyyy format
  • AND
  • Agent’s Name
  • Agent’s Address
  • Agent’s Phone Number
  • Principal must read the remaining portion of the section
  • AND
  • Enter a Successor Agent in case the initial agent is no longer able or willing to serve
  • Enter the Successor’s complete street address

Step 2 – Principal’s Statement of Desires, Special Provisions and Limitations about Health Care – The Principal must read the information in this section, The Principal must then read the various statement and initial the ones for which the Principal would like to implement

  • If the Principal is near death and lacks the capacity to make health care decisions, authorize the agent to direct that:
  • Life-sustaining treatment not be started, or if started, be discontinued
  • OR
  • Life-sustaining treatment continue to be given to the Principal
  • Whether near death or not, if the Principal should become permanently unconscious, authorize the agent to direct  life-sustaining treatment not be started, or if started, be discontinued
  • OR
  • Life-sustaining treatment continue to be given

Step 3 – Medically Administered Nutrition and Hydration – The Principal must specify:

  • In the event the Principal is near death –
  • Medically administered nutrition and hydration not be started, or if started, be discontinued
  • OR
  • Even if all other forms of life-sustaining treatment have been withdrawn, medically administered nutrition and hydration continue to be given to the Principal

Step 4 – Explaining the Principal’s Instructions in More Detail – The Principal must initial those statement in which they are in agreement:

  • Grant the agent authority to request or agree to a DNR order
  • Make clear the Principal’s intent that my agent shall have full authority to make any and all health care decision(s) on behalf (of the Principal)
  • Even if the Principal is incapacitated and objects to treatment, treatment may be given to the Principal, or withheld, against their objection…
  • In the lines provided the Principal may add specific instructions for the Agent. If there are no other instructions, leave the section blank
  • Enter the location where an original of the directive may be found if needed.
  • List, also, any other persons or institutions where a copy of the document may be found if needed

Step 5 – Signatures – Must be signed before a Notary Public

  • Date the signature in dd/mm/yyyy format
  • The Principal must enter their signature

Step 6 – Witnesses Declaration – The Witnesses must review the declaration.

  • If in agreement the statement, the witnesses must enter their signatures
  • Enter the addresses of the witnesses

Step 7 – Living Will – Should the Principal choose to complete the living will:

  • Enter the date of the declaration in dd/mm/yyyy format
  • Enter the Principal’s name
  • Review the entire section
  • Initial either A or B
  • Print the name of the Principal
  • Enter the Principal’s Date of Birth in mm/dd/yyyy format
  • The Principal must declare that they are of sound mind to complete the document
  • Date the signature dd/mm/yyyy
  • The Principal must submit their signature

Step 8 – Witnesses – The Witnesses must read the declaration

  • If in agreement, the witnesses must enter their signatures
  • Enter the witnesses addresses

Step 9 – Notarization –

  • Once the notary has witnessed all signatures, the Notary will then complete the information, acknowledging the validity of the document