New Mexico Medical Power of Attorney Form | |
The New Mexico medical power of attorney form is a document that a Principal shall utilize to name an Agent to whom the Principal would grant specific powers that would allow the Agent to make decisions regarding the health care of the Principal when they are incapacitated or no longer able to communicate their wishes on their own. This document will not grant powers allowing the health care Agent to make any decisions with regard to finances or property, whether it would be real property or personal.
The Principal should be certain that they would be as specific as possible, communicating their health care wishes in writing and while of sound mind to ensure that all parties involved will follow your instructions exactly. This document is a “durable” statement, meaning, it will remain in effect even when you are no longer available to communicate either way about the state of your health care, especially in an end of life situation. If the Principal is unclear with regard to the language, they may wish to contact an attorney for assistance.
This Principal is welcome to revoke this document at any time, in writing and by delivery to the Agent.
How to Write
Step 1 – Establishing the Principal – Provide the following:
- The name of the Principal
- Principal’s County of Residence
Step 2 – Designation of Agent – Enter:
- Agent’s Name
- Agent’s Address
- Agent’s Telephone Number
Step 3 – Designation of Successor Agent(s)
Should the original Agent, elected by the Principal become ill, unable or unwilling to act on behalf of the Principal, the Principal may choose to select Successor Agent’s to quickly pick up the responsibilities for the health care decisions for the Principal:
- Name of Successor Agent(s)
- Successor Agent(s) Address(es)
- Successor Agent(s) Telephone Number(s)
Step 4 – Agent’s Authority –
The Principal may provide authority to review medical records, reports and any other information, to assist in making decisions as health care declines. Principal must read the statement. Add any other specific instructions and wishes on the lines provided on the form
Step 5 – When Agent’s Authority Shall Become Effective:
The Principal must review the statements on the form and initial either box A or B as follows:
- Agent’s authority becomes effective immediately unless the Principal would have revoked the Agent’s authority
- OR
- Agent’s authority shall become effective only if the Principal should become incapacitated. My agent will be entitled to rely on notarized statements from two qualified health care professionals as to the Principal’s incapacity
Step 6 – Review the Next Three Statements as follows on the form:
- Agent’s Obligation
- Nomination of Guardian
- Durability
Step 7 – Instructions for Health Care –
The Principal must read and apply their instructions by initialing the boxes that will indicate their end of life wishes. These instructions are to be closely followed by both the Agent and Health Care providers:
- I choose not to Prolong Life I do not want my life to be prolonged
- OR
- I choose To Prolong Life I want my life to be prolonged as long as possible within the limits of generally accepted health-care standards.
Step 8 – Artificial Nutrition and Hydration –
- I do not want artificial nutrition
- OR
- I DO want artificial nutrition
Step 9 – Relief From Pain –
- The Principal must read the statement in this section. If any there are any special wishes or instruction, besides what is stated, enter them on the lines provided
Step 10 – Anatomical Gift Designation –
The Principal may mark their decisions by initialing the field that best indicates their desires:
- The Principal chooses to make an anatomical gift of all of my organs or tissue to be determined by medical suitability at the time of death, and artificial support may be maintained long enough for organs to be removed
- OR
- The Principal shall Choose to make a partial anatomical gift of some of my organs or tissue as specified below, and artificial support may be maintained long enough for organs to be removed. The following organs and tissue may be donated
- OR
- The Principal refuses to make an anatomical gift of any of my organs or tissue
Step 11 – Other Wishes –
- Should the Principal have other wishes they would like to record in writing, place them within the lines provided in this section on the form. If more space is needed continue on a separate sheet and remember to sign and date the added sheet as well
Step 12 – Designation of Primary Physician –
The Principal may designate their Primary Care Physician and/or facility:
- Name of physician
- Address
- City, State, Zip Code
- Phone
Should the Physician be unwilling or unreasonably available the Principal may select a second option:
- Name of physician
- Address
- City, State, Zip Code
- Phone
Step 13 – Revocation –
The Principal should read this section in the event they may find that they would like to revoke this document. The document may be revoked in writing to the agent or by immediately contacting their health care provider.
Step 14 – Signatures – The Principal must provide the following:
- Principal’s Signature
- Printed Name
- Date of signature in mm/dd/yyyy format
- Street Address, City, State, Zip Code
Step 15 – Witnesses –
Signatures of witnesses are not required, however, witnesses signatures are recommended – Should the Principal decide upon using witnesses, provide the following for each witness:
- Witnesses Signatures
- Printed Names
- Date of Signatures in mm/dd/yyyy format
- Addresses
- City, State, Zip Codes