New Hampshire Medical Power of Attorney Template
This Medical Power of Attorney is created in accordance with New Hampshire state laws, allowing you to appoint an individual to make medical decisions on your behalf when you are unable to do so. This document ensures that your healthcare preferences are respected and followed.
Principal Information:
- Name: ______________________________
- Address: ____________________________
- City, State, Zip: ____________________
- Date of Birth: ______________________
Agent Information:
- Name: ______________________________
- Address: ____________________________
- City, State, Zip: ____________________
- Phone Number: ______________________
Durable Power of Attorney:
I, the undersigned, hereby designate the above-named Agent as my Medical Power of Attorney. This authority shall remain in effect even if I become incapacitated or unable to make my own medical decisions.
Scope of Authority:
The Agent shall have the authority to make decisions regarding my medical treatment, including but not limited to:
- Consent to or refuse medical treatment
- Access my medical records
- Make decisions regarding life-sustaining treatment
- Choose healthcare providers and facilities
Instructions and Preferences:
It is my wish that my Agent considers the following preferences when making healthcare decisions:
______________________________________________________
______________________________________________________
Revocation of Prior Powers of Attorney:
This document revokes any prior Medical Powers of Attorney executed by me.
Signatures:
By signing below, I affirm that I am of sound mind and that I understand the implications of this document.
Principal Signature: ___________________________ Date: _______________
Agent Signature: _____________________________ Date: _______________
Witnesses:
- Name: ______________________________ Signature: __________________________ Date: _______________
- Name: ______________________________ Signature: __________________________ Date: _______________
Notary Public:
State of New Hampshire
County of ____________________________
Subscribed and sworn to before me this _____ day of ____________, 20__.
Notary Public Signature: ______________________________
My Commission Expires: _____________________________