Medical Power Of Attorney printable pdf download

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Medical Power of Attorney

I, ___________________________, presently residing at_______________________________,

New Jersey, do constitute and appoint_______________________________, my true and lawful

Health Care Representative, to exercise the powers set out in this Medical Power of Attorney as

fully and effectually as I could do at a time when I may lack decision-making capacity as defined

in the New Jersey Advance Directives for Health Care Act, for me and in my name, to act for the

following purposes:

1. General medical decisions

a. Provide or withhold consent to any medical procedure, tests or treatments including

surgery

b. Provide or withhold consent for hospitalization, convalescent care, hospice or home care

c. Provide or withhold consent for end-of-life decisions such as DNR order or

withholding/withdrawal of life-sustaining medical treatment

d. Ensure that I am comfortable and as pain free as possible

2. Psychological/psychiatric care

a. Provide

withhold

consent

for

psychological,

psychiatric,

behavioral

pharmacological treatment

3. Access and release of health care information

a. My Health Care Representative is also hereby designated as my “Personal

Representative” as defined by 45 CFR 164.502(g), commonly known as the Health

Insurance Portability and Accountability Act of 1996 (HIPAA). This individual is to

have the same access to my health care and treatment information as I would have

myself.

b. Request, receive and review any information, oral or written, about my mental or

physical health

c. Release any information, oral or written, about my mental or physical health to

professional and administrative personnel as needed

4. Funeral arrangements

a. Make arrangements for my funeral and burial according to my religious preferences or

expressed wishes

5. Anatomical gifts

a. Provide or withhold consent for anatomical gifts upon my death

This Medical Power of Attorney shall not be affected by my disability or incompetence.

Medical Power Of Attorney