Content Overview
The New Hampshire Medical Power of Attorney form serves as a crucial legal document that empowers individuals to designate someone they trust to make healthcare decisions on their behalf in the event they become unable to do so themselves. This form is particularly important for ensuring that a person's medical preferences are honored, even when they cannot communicate them. It allows the appointed agent to make choices regarding medical treatment, including life-sustaining measures, based on the individual's wishes or best interests. The form also requires clear identification of both the principal—the person granting authority—and the agent, along with any specific instructions or limitations the principal wishes to impose. Furthermore, New Hampshire law mandates that the document be signed in the presence of a notary public or two witnesses, ensuring its validity and reducing the potential for disputes. Understanding the nuances of this form can provide peace of mind, knowing that healthcare decisions will reflect one’s values and preferences during critical times.
New Hampshire Medical Power of Attorney Sample
New Hampshire Medical Power of Attorney
This Medical Power of Attorney is a legal document that grants authority to an individual (Agent) to make healthcare decisions on behalf of the person creating the document (Principal) in the event that the Principal is unable to make such decisions themselves. This document is in accordance with the New Hampshire Revised Statutes Annotated (RSA) Chapter 137-J, known as the “Advance Directives” law.
Please complete the following information to establish a Medical Power of Attorney in the state of New Hampshire:
Principal Information
- Full Name: ___________________________________
- Address: _____________________________________
- City: _______________, State: New Hampshire, Zip: ________
- Date of Birth: ___________________
- Phone Number: _____________________
Agent Information
- Full Name: ___________________________________
- Relationship to Principal: _____________________
- Address: _____________________________________
- City: _______________, State: ________________, Zip: ________
- Alternate Phone Number: ______________________
Alternate Agent Information (Optional)
If the primary Agent is unable or unwilling to serve, an alternate Agent can make healthcare decisions for the Principal. Complete the information below for an alternate Agent (optional):
- Full Name: ___________________________________
- Relationship to Principal: _____________________
- Address: _____________________________________
- City: _______________, State: ________________, Zip: ________
- Alternate Phone Number: ______________________
In the event the Principal is unable to make healthcare decisions, the Agent is granted full authority to make medical decisions on behalf of the Principal, including but not limited to:
- Consenting, refusing, or withdrawing consent to any medical treatment, service, or procedure to maintain, diagnose, or treat a physical or psychological condition.
- Having access to medical records and information needed to make informed decisions about the Principal's care.
- Making decisions about the Principal's admission to or discharge from medical facilities such as hospitals, nursing homes, or hospices.
This Medical Power of Attorney becomes effective immediately upon signing and remains effective until it is revoked or the Principal regains the ability to make decisions.
Signature of Principal
_____________________________________
Date: ________________
Signature of Agent
_____________________________________
Date: ________________
To ensure the validity of this document, it is recommended to have the signatures witnessed or notarized in accordance with New Hampshire law.
Witness/Notary Acknowledgment
This section should be completed by a notary public or two adult witnesses, neither of whom is the designated agent, attesting to the Principal's understanding and voluntary signing of this document.
Witness 1 Signature: ____________________________
Print Name: _____________________________
Date: __________________________________
Witness 2 Signature: ____________________________
Print Name: _____________________________
Date: __________________________________
OR
Notary Public Signature: __________________________
Notary Public Name: _________________________
Commission Expires: _________________________
Seal:
PDF Specs
| Fact Name | Description |
|---|---|
| Definition | A New Hampshire Medical Power of Attorney allows an individual to designate someone to make medical decisions on their behalf if they become incapacitated. |
| Governing Law | This form is governed by New Hampshire Revised Statutes Annotated (RSA) 137-J:1 through 137-J:9. |
| Principal | The person who creates the Medical Power of Attorney is known as the principal. |
| Agent | The designated individual who will make medical decisions is referred to as the agent or attorney-in-fact. |
| Capacity Requirement | The principal must be at least 18 years old and capable of understanding the nature of the document when signing. |
| Signature Requirement | The form must be signed by the principal in the presence of two witnesses or a notary public. |
| Revocation | The principal can revoke the Medical Power of Attorney at any time, provided they are still competent to do so. |
| Healthcare Decisions | The agent has the authority to make a wide range of healthcare decisions, including treatment options and end-of-life care. |
| Durability | This Medical Power of Attorney remains effective even if the principal becomes incapacitated. |
| Additional Provisions | The principal may include specific instructions or limitations regarding the agent's authority within the document. |
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