Free New Mexico Medical Power of Attorney Form

New Mexico Medical Power of Attorney

This Medical Power of Attorney is a legal document that allows an individual, known as the Principal, to designate another person, called the Agent, to make health care decisions on their behalf if they are unable to do so. This document is specifically tailored for use within the State of New Mexico and is in compliance with the New Mexico Uniform Health-Care Decisions Act.

Principal Information:

• Full Name: ______________________________
• Address: ________________________________
• City: ___________________ State: NM Zip Code: ___________
• Date of Birth: ___________________________
• Social Security Number: __________________

Agent Information:

• Full Name: ______________________________
• Address: ________________________________
• City: ___________________ State: NM Zip Code: ___________
• Phone Number: ___________________________
• Alternate Phone Number: _________________

In accordance with the New Mexico Uniform Health-Care Decisions Act, the Principal designates the following individual as their Agent to make health care decisions on their behalf:

Scope of Authority:

1. The Agent is authorized to make any and all health care decisions on the Principal's behalf that the Principal could make if capable, including decisions about choosing or refusing medical treatment, services, and procedures, and decisions about withdrawing or withholding lifesaving measures.
2. The Agent's authority is effective when the Principal is determined to be unable to make their own health care decisions by the attending physician.
3. The Agent is obligated to make decisions based on the known wishes of the Principal. If the Principal's wishes are unknown, the Agent should make decisions in the Principal's best interests.

Special Instructions:

(Optional) Here, the Principal can specify limitations on the Agent’s authority, state any specific wishes regarding health care treatments, or provide any other instructions.

___________________________________________

Effective Date:

This Medical Power of Attorney becomes effective immediately unless specified otherwise and remains in effect until it is revoked by the Principal.

Witnesses:

The law requires that this document be signed in the presence of two adult witnesses, who must also sign and print their names, stating they witnessed the Principal sign this document or acknowledged it and believe the Principal to be of sound mind.

Witness 1:

• Full Name: ______________________________
• Signature: ______________________________
• Date: ___________________________________

Witness 2:

• Full Name: ______________________________
• Signature: ______________________________
• Date: ___________________________________

By signing this Medical Power of Attorney, the Principal acknowledges their understanding of its contents and affirms their right to make health care decisions. This document should be a part of the Principal's medical records.

Principal's Signature: ___________________________ Date: ___________

Agent's Signature: _____________________________ Date: ___________