New Hampshire Medical Power of Attorney
This Medical Power of Attorney is made according to the New Hampshire Durable Power of Attorney for Health Care Act (RSA 137-J). It grants the authority to a chosen agent to make health care decisions on the principal's behalf should they become unable to make decisions for themselves.
Part 1: Principal Information
Principal's Full Name: ___________________________________
Principal's Date of Birth: ___________________________________
Principal's Address: ___________________________________
City: _______________________, State: New Hampshire, Zip Code: _______________
Part 2: Agent Information
Agent's Full Name: ___________________________________
Agent's Relationship to Principal: ___________________________________
Agent's Address: ___________________________________
City: _______________________, State: _______________, Zip Code: _______________
Agent's Phone Number: ___________________________________
Alternate Phone Number: ___________________________________
Part 3: Powers Granted
This document grants the named agent the power to make any and all health care decisions for the principal that the principal could make if capable, including decisions to refuse or consent to treatment, to access medical records, and to make decisions about the withdrawal of life-sustaining treatment, within the limits prescribed by law.
Part 4: Alternate Agent
If the initially chosen agent is unable or unwilling to serve, the following person is designated as the alternate agent:
Alternate Agent's Full Name: ___________________________________
Alternate Agent's Relationship to Principal: ___________________________________
Alternate Agent's Address: ___________________________________
City: _______________________, State: _______________, Zip Code: _______________
Alternate Agent's Phone Number: ___________________________________
Alternate Phone Number: ___________________________________
Part 5: Special Instructions
Any specific limitations to the agent's decision-making authority, preferences about specific medical treatments, or other special instructions should be listed here:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Part 6: Signatures
This Medical Power of Attorney will not be effective unless it is signed in the presence of two adult witnesses or a notary public. The witnesses cannot be the agent, the alternate agent, health care provider, or anyone entitled to any portion of the principal's estate upon death.
Principal's Signature: ___________________________________ Date: _______________
Witness 1 Signature: ___________________________________ Date: _______________
Witness 2 Signature: ___________________________________ Date: _______________
or
Notary Public Signature: ___________________________________ Date: _______________
My commission expires: _______________