Legal Medical Power of Attorney Template for New Jersey

This Medical Power of Attorney is established in accordance with the laws of the State of New Jersey, specifically the New Jersey Advance Directive for Health Care Act. It empowers the individual(s) named herein to make healthcare decisions on behalf of the undersigned, should the undersigned become unable to participate in medical treatment decisions.

Part 1: Information of the Principal

Full Name of Principal: _______________________________________

Principal's Date of Birth: _____________________________________

Address of Principal: __________________________________________

City, State, Zip: ______________________________________________

Principal's Telephone Number: __________________________________

Part 2: Designation of Health Care Representative

I, ______________________ (Principal's name), hereby designate the following individual as my Health Care Representative to make health care decisions on my behalf:

Full Name of Health Care Representative: ________________________

Relationship to Principal: _____________________________________

Address of Health Care Representative: __________________________

City, State, Zip: ______________________________________________

Health Care Representative's Telephone Number: __________________

Alternate Health Care Representative

If my primary Health Care Representative is unable, unwilling, or unavailable to act in such capacity, I hereby designate the following individual as my alternate Health Care Representative:

Full Name of Alternate Health Care Representative: ______________

Relationship to Principal: _____________________________________

Address of Alternate Health Care Representative: ________________

City, State, Zip: ______________________________________________

Alternate Health Care Representative's Telephone Number: _________

Part 3: Health Care Decisions

My Health Care Representative is authorized to make all health care decisions on my behalf, including but not limited to, decisions regarding medical treatment, surgical interventions, and end-of-life care, consistent with the desires I have expressed herein or otherwise communicated.

In the absence of specific instructions from me, my Health Care Representative is to make decisions based on what they believe to be in my best interests, considering my personal values to the extent known to them.

Part 4: Specific Limitations

If there are specific treatments or procedures I do not want under any circumstances, they are listed here:

________________________________________________________________

Part 5: Organ Donation

Upon my death, I wish to donate my organs.

• Only the following organs or parts: ___________________________
• Any needed organs or parts for transplantation.
• I do not wish to donate any organs or parts.

Part 6: Signature

This document is effective upon my signature and remains in effect until revoked by me or upon my death.

________________________________ ____________________________

Signature of Principal Date

Part 7: Witness Declaration

This Medical Power of Attorney was signed in my presence by _____________________ (Principal's name) who appears to be of sound mind and under no duress or undue influence. I am not related to the Principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the Principal under a will now existing or by operation of law.

________________________________ ____________________________

Signature of Witness 1 Date

________________________________ ____________________________

Signature of Witness 2 Date