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New Jersey Durable Power of Attorney for Health Care Form

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New Jersey Durable Power of Attorney for Health Care Form Page 2
New Jersey Durable Power of Attorney for Health Care Form
The New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care
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(If you have any additional specific instructions concerning your care you may use the space below or attach an
additional statement.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
D) COPIES: The original or a copy of this document has been given to my health care representative and to the
following:
1. name ___________________________________
address _________________________________
city ________________________ state _______ telephone __________________________
2. name ___________________________________
address _________________________________
city ________________________ state _______ telephone __________________________
E) SIGNATURE: By writing this durable power of attorney for health care, I inform those who may become
entrusted with my care of my health care wishes and intend to ease the burdens of decision making which this
responsibility may impose. I have discussed the terms of this designation with my health care representative and
he or she has willingly agreed to accept the responsibility for acting on my behalf in accordance with my wishes
as expressed in this document. I understand the purpose and effect of this document and sign it knowingly,
voluntarily and after careful deliberation.
Signed this _____________ day of ______________, 20______.
signature _____________________________________________
address ______________________________________________
city ____________________________________ state_________
F) WITNESSES: I declare that the person who signed this document, or asked another to sign this document on
his or her behalf, did so in my presence, that he or she is personally known to me, and that he or she appears to be
of sound mind and free of duress or undue influence. I am 18 years of age or older, and am not designated by this
or any other document as the person’s health care representative, nor as an alternate health care representative.
1. witness____________________________________ 2. witness _______________________________
address ___________________________________ address ______________________________
city _______________________ state __________ city ____________________ state _________
signature _________________________________ signature _____________________________
date ______________________________________ date _________________________________
New Jersey Durable Power of Attorney for Health Care Form
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