New Mexico Medical Power of Attorney
This document grants designated individuals the authority to make medical decisions on behalf of the undersigned, as per the New Mexico Uniform Health-Care Decisions Act (Sections 24-7A-1 to 24-7A-18 NMSA 1978).
Principal Information
Name of Principal: ____________________________________
Address: ____________________________________
City, State, Zip: ____________________________________
Date of Birth: ____________________________________
Social Security Number: ____________________________________
Agent Information
Name of Agent: ____________________________________
Relationship to Principal: ____________________________________
Primary Phone Number: ____________________________________
Alternate Phone Number: ____________________________________
Email Address: ____________________________________
Alternate Agent Information (Optional)
If the primary agent is unable or unwilling to perform, an alternate agent can act on the principal's behalf.
Name of Alternate Agent: ____________________________________
Relationship to Principal: ____________________________________
Primary Phone Number: ____________________________________
Alternate Phone Number: ____________________________________
Email Address: ____________________________________
Authority Granted
The undersigned principal hereby grants authority to the above-named agent to make all healthcare decisions on their behalf, including but not limited to:
- Consenting or refusing consent to any medical care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
- Access to medical records.
- Deciding on the principal's admission to or discharge from a healthcare facility.
- Authority to donate organs and tissues following the principal's death.
Limitations of Authority
The principal may state any specific limitations here:
____________________________________________________________________________________
____________________________________________________________________________________
Effective Date and Signature
This Medical Power of Attorney shall become effective on the date signed by the principal and shall remain in effect indefinitely unless specified otherwise below or until revoked in writing by the principal.
Date: ____________________________________
____________________________________
Signature of Principal
State of New Mexico
County of ____________________
Subscribed and sworn to (or affirmed) before me on this ___ day of ________________, 20___, by _______________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument.
____________________________________
Signature of Notary Public
My commission expires: ______________
Witness Statement
Under New Mexico law, this Medical Power of Attorney must be signed in the presence of two witnesses, who also need to sign the document, affirming that the principal is known to them, that the principal signed or acknowledged their signature on this document in their presence, and that the principal appears to be of sound mind and under no duress or undue influence.
Witness 1:
Name: ____________________________________
Signature: __________________________________
Date: __________________________________
Witness 2:
Name: ____________________________________
Signature: __________________________________
Date: __________________________________