New Mexico Medical Power of Attorney
This Medical Power of Attorney is a legal document that grants a chosen individual the authority to make health care decisions on behalf of the principal when they are unable to do so due to illness or incapacitation. The powers granted here are governed by the New Mexico Uniform Health-Care Decisions Act (Sections 24-7A-1 to 24-7A-18 NMSA 1978).
Principal Information:
Full Name: ________________________________________________________
Address: _________________________________________________________
City: _______________________ State: NM Zip Code: __________________
Date of Birth: ____________________ Telephone: ____________________
Agent Information:
Full Name of Agent: ________________________________________________
Address: _________________________________________________________
City: _______________________ State: NM Zip Code: __________________
Telephone: ____________________ Email: ____________________________
Alternate Agent Information: (Optional)
Full Name of Alternate Agent: _______________________________________
Address: _________________________________________________________
City: _______________________ State: NM Zip Code: __________________
Telephone: ____________________ Email: ____________________________
Should the primary Agent be unable or unwilling to serve, the Alternate Agent will assume the same powers as the initial Agent.
Powers Granted:
By this document, I, the Principal, appoint the Agent named above to make health care decisions on my behalf as authorized in this document, in accordance with my wishes, religious and moral beliefs, and under the guidelines of the New Mexico Uniform Health-Care Decisions Act. These decisions may include choosing medical treatment, accessing medical records, and making end-of-life decisions.
The Agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless otherwise stated here: ____________________________________________________________.
Special Instructions:
Here, you may include any specific wishes, limitations, or the provision for your health care, including, but not limited to, treatments you would prefer or refuse:
________________________________________________________________________________________________________________________________________________________________________________________________________
Signatures:
This document must be signed by the Principal, an attorney-at-law, or another adult in the presence of two (2) adult witnesses or a notary public. The witnesses must not be related to the Principal by blood, marriage, or adoption and cannot be entitled to any portion of the Principal's estate upon death.
Principal's Signature: ______________________________ Date: _________
Agent's Signature: _________________________________ Date: _________
Alternate Agent's Signature: (If applicable) __________________________ Date: _________
Witness 1: ________________________________________ Date: _________
Witness 2: ________________________________________ Date: _________
Notarization: (If applicable)
This section should be completed by a notary public if not using witnesses.
State of New Mexico )
County of ___________ )
On this day of ___________, 20__, before me, a notary public, personally appeared ______________________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument, and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
Notary Public: _____________________________________
My commission expires: ______________________________
