New Jersey Medical Power of Attorney
This Medical Power of Attorney is created in accordance with the laws of the State of New Jersey. It allows you to designate a trusted individual to make medical decisions on your behalf in the event that you are unable to do so.
Principal Information:
- Name: ___________________________
- Address: ___________________________
- City, State, Zip: ___________________________
- Date of Birth: ___________________________
Agent Information:
- Name: ___________________________
- Address: ___________________________
- City, State, Zip: ___________________________
- Phone Number: ___________________________
Effective Date: This Medical Power of Attorney shall become effective on:
___________________________ (date)
Authority Granted:
The Agent shall have the authority to make medical decisions on my behalf, including but not limited to:
- Deciding on medical treatments and procedures.
- Accessing my medical records.
- Choosing healthcare providers and facilities.
- Making end-of-life decisions in accordance with my wishes.
Revocation: This Medical Power of Attorney may be revoked by me at any time, provided that I communicate my intent to revoke to my Agent and any relevant healthcare providers.
Signature:
___________________________ (Principal's Signature)
___________________________ (Date)
Witnesses:
Two witnesses must sign below. They cannot be the Agent or related to the Principal.
- ___________________________ (Witness 1 Signature)
- ___________________________ (Date)
- ___________________________ (Witness 2 Signature)
- ___________________________ (Date)
Notary Public:
State of New Jersey, County of _______________
Subscribed and sworn to before me this ____ day of __________, 20__.
___________________________ (Notary Public Signature)
My commission expires: ________________