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New Mexico Durable Power of Attorney for Health Care Form

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New Mexico Durable Power of Attorney for Health Care Form
New Mexico Durable Power of Attorney for Health Care Form
1
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
I, _______________________, reside in ____________________ County, New Mexico:
(1) DESIGNATION OF AGENT: I designate the following individual as my agent to
make health-care decisions for me:
Name of Agent:
Agent’s Address:
Agent’s Telephone Number:
DESIGNATION OF SUCCESSOR AGENT(S)
(OPTIONAL)
If I revoke my agent's authority or if my agent is not willing, able or reasonably available
to make a health-care decision for me, I designate as my successor agent:
Name of Successor Agent:
Successor Agent’s Address:
Successor Agent’s Telephone Number:
If I revoke the authority of my agent and first alternate agent or if neither is willing, able
or reasonably available to make a health-care decision for me, I designate as my second
successor agent:
Name of Second Successor Agent: ________________________________________________
Second Successor Agent’s Address: _______________________________________________
Second Successor Agent’s Telephone Number: ______________________________________
New Mexico Durable Power of Attorney for Health Care Form
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