Optional Advance Health Care Directive
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4State Bar of New Mexico Special Projects, Inc.
L
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AWYER
EFERRAL
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P
OR THE
LDERLY
ROGRAM
Post Office Box 92860 / Albuquerque, New Mexico
87199-2860
(505) 797-6005 / (800) 876-6657 / FAX (505) 797-6074 / E-mail:
OPTIONAL ADVANCE HEALTH-CARE DIRECTIVE
THIS FORM IS OPTIONAL. Each paragraph and word of this form is also optional. If you use this form, you
may cross out, complete or modify all or any part of it. You are free to use a different form.
If you use this form, be sure to sign it and date it.
PART I
POWER OF ATTORNEY FOR HEALTH CARE
PART 1 of this form is a power of attorney for health care. PART 1 lets you name another individual as agent to make health-care decisions for you
if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still
capable. You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for
you. Unless related to you, your agent may not be an owner, operator or employee of a health-care institution at which you are receiving care.
Unless the form you sign limits the authority of your agent, your agent may make all health-care decisions for you. This form has a place for you to
limit the authority of your agent.
This part is the health-care power-of-attorney form, which allows you to name an individual to act as
your agent to make health care decisions for you
(1)
DESIGNATION OF AGENT: I, ___________________________, name the following individual as
my agent to make health-care decisions for me:
_______________________________________________________________
Name
Phone Number
_______________________________________________________________
Address
City
State
Zip Code
If I revoke my agent’s authority or if my agent is not willing, able or reasonably available to make a health-care
decision for me, I designate as my first alternate agent:
_______________________________________________________________
Name
Phone Number
_______________________________________________________________
Address
City
State
Zip Code
If I revoke the authority of my agent and first alternate agent or if neither is willing, able or reasonably
available to make a health-care decision for me, I designate as my second alternate agent:
_______________________________________________________________
Name
Phone Number
_______________________________________________________________
Address
City
State
Zip Code
This Program is funded by:
The Aging and Long Term Services Department, the NM Civil Legal Services Commission, and the State Bar of New Mexico
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