Free Health Care Directive

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Health Care Directive

Your Health Care Agent


Your Health Care Agent

Who are you appointing as your Health Care Agent?
In other words, who would you like to make health care decisions for you should you become unable to do so yourself?

Health Care Agent

e.g. Jamie Taylor Lee

New Hampshire


e.g. 202 Pine Avenue

e.g. Concord



e.g. Spouse, Brother, Friend, etc.





Frequently Asked Questions
Who can act as my Health Care Agent?Anyone over the age of majority and of sound mind can act as your Health Care Agent. Spouses and close family members are common choices.When does my agent's authority begin?Your agent's authority begins when you become incapable of directing your own health care. During your incapacity, your agent will be given access to your health records and will be authorized to sign releases or other necessary documents on your behalf. At any time, if you are capable of making your own decisions, you may do so. Your agent will not have authority to act for you in matters unrelated to your health care. Will this information be kept private?Yes. LawDepot® is committed to protecting your privacy and ensuring that your visit to our website is completely secure. For more information, see our Privacy Policy.


Your Health Care Directive

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DISCLOSURE STATEMENT
INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY FOR HEALTH CARE

THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS:

Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you when you are no longer capable of making them yourself. "Health care" means any treatment, service or procedure to maintain, diagnose or treat your physical or mental condition. Your agent, therefore, can have the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment. Your agent cannot consent or direct any of the following: commitment to a state institution, sterilization, or termination of treatment if you are pregnant and if the withdrawal of that treatment is deemed likely to terminate the pregnancy unless the failure to withhold the treatment will be physically harmful to you or prolong severe pain which cannot be alleviated by medication.

You may state in this document any treatment you do not desire, except as stated above, or treatment you want to be sure you receive. Your agent's authority will begin when your doctor certifies that you lack the capacity to make health care decisions. If for moral or religious reasons you do not wish to be treated by a doctor or examined by a doctor for the certification that you lack capacity, you must say so in the document and name a person to be able to certify your lack of capacity. That person may not be your agent or alternate agent or any person ineligible to be your agent. You may attach additional pages if you need more space to complete your statement.

If you want to give your agent authority to withhold or withdraw the artificial providing of nutrition and fluids, your document must say so. Otherwise, your agent will not be able to direct that. Under no conditions will your agent be able to direct the withholding of food and drink for you to eat and drink normally.

Your agent will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent will have the same authority to make decisions about your health care as you would have had if made consistent with state law.

It is important that you discuss this document with your physician or other health care providers before you sign it to make sure that you understand the nature and range of decisions which may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgeable about these issues and can answer your questions. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.

The person you appoint as agent should be someone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your physician, or an employee of a home health agency, hospital, nursing home, or residential care home, other than a relative), that person will have to choose between acting as your agent or as your health or residential care provider; the law does not permit a person to do both at the same time.

You should inform the person you appoint that you want him or her to be your health care agent. You should discuss this document with your agent and your physician and give each a signed copy. You should indicate on the document itself the people and institutions who will have signed copies. Your agent will not be liable for health care decisions made in good faith on your behalf.

Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing him or her or your health care provider orally or in writing.

This document may not be changed or modified. If you want to make changes in the document you must make an entirely new one.

You should consider designating an alternate agent in the event that your agent is unwilling, unable, unavailable, or ineligible to act as your agent. Any alternate agent you designate will have the same authority to make health care decisions for you.

THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO (2) OR MORE QUALIFIED WITNESSES WHO MUST BOTH BE PRESENT WHEN YOU SIGN AND ACKNOWLEDGE YOUR SIGNATURE. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:

  • the person you have designated as your agent;
  • your spouse; or
  • your lawful heirs or beneficiaries named in your will or a deed.

ONLY ONE OF THE TWO WITNESSES MAY BE YOUR HEALTH OR RESIDENTIAL CARE PROVIDER OR ONE OF THEIR EMPLOYEES.

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

APPOINTMENT OF AGENT
I, _________________________, of ____________________________, New Hampshire __________, hereby appoint _______________________ as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document or as prohibited by law. _______________________ can be contacted at:

Address: _______________________
City/State: _______________________, New Hampshire __________
Phone: ______________________________

This durable power of attorney for health care shall take effect in the event I become unable to make my own health care decisions.

STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS REGARDING HEALTH CARE DECISIONS
My agent is authorized to act for all matters relating to my health care, including, full power to give or refuse consent to all medical, surgical, hospital and related health care, according to my wishes as stated in this declaration. This power includes, but is not limited to, the authority to:

  • make decisions on whether to provide, withhold, or withdraw artificial nutrition and hydration;
  • review and receive any information regarding my physical or mental health, including medical and hospital records, in accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA");
  • sign any releases in order to obtain this information;
  • sign any documents required to request, withdraw, or refuse treatment or to be released or transferred to another medical facility.

My agent does not have authority to act for me for any purpose unrelated to the provision to me of health care. All of my agent's actions under this power during any period when I am unable to make or communicate health care decisions have the same effect on my heirs, devisees and personal representatives as if I were competent and acting for myself.

I direct that my agent make health care decisions in accordance with my duly executed Living Will, which is attached to this document. If my Living Will directs that artificial food and water be withheld from me in certain circumstances, I intend that my agent have the authority to direct that artificial nutrition and hydration be withheld or withdrawn from me in those circumstances.

EFFECT OF COPY
A copy of this document has the same effect as the original.

The remainder of this document will be available when you have purchased a license.


When creating a document, LawDepot’s template gives you the following options:

  • Only specify your health care preferences
  • Only appoint someone to make medical decisions for you
  • Specify your health care preferences and appoint someone to make medical decisions for you

Related documents

  • Power of Attorney: Grant someone authority to act on your behalf regarding your finances, family, or property if you become incapacitated or are away for a long period of time.
  • Last Will and Testament: Document your wishes on how you’d like your estate divided when you pass away.
  • Child Medical Consent: Give a temporary guardian the authority to make medical decisions on behalf of your child.
  • Medical Records Release: Request that your medical records be released to you or a third party.
  • End-of-Life Plan: Outline your wishes for memorial services and what to do with your remains after you pass away.

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