New Jersey Power of Attorney
I, [Your Name], residing at [Your Address], hereby designate and appoint [Agent's Full Name], residing at [Agent's Address], as my Attorney-in-Fact to act on my behalf in making healthcare decisions if I become unable to make such decisions for myself.
I. AUTHORITY GRANTED
I hereby grant my Attorney-in-Fact full authority to make any healthcare decisions on my behalf, including but not limited to:
(a). Consent to or refusal of medical treatment, surgical procedures, medications, and other healthcare services.
(b). Admission to or discharge from any hospital, nursing home, or other healthcare facility.
(c). Access to my medical records and the authority to disclose my medical information as necessary.
(d). Making decisions regarding life-sustaining treatments, including the withholding or withdrawal of such treatments, by my wishes as stated below.
II. LIMITATIONS:
The authority granted to my Attorney-in-Fact shall not include the power to consent to any of the following:
a. Psychosurgery.
b. Sterilization.
c. Abortion.
d. Admission to or retention in a mental health care facility for longer than 20 consecutive days unless judicially determined.
DURATION:
This Power of Attorney for Healthcare Decisions shall remain in effect indefinitely unless revoked by me in writing.
III. SUBSTITUTE AGENT
If my designated Attorney-in-Fact is unable, unwilling, or unavailable to act on my behalf, I hereby designate [Alternate Agent's Full Name], residing at [Alternate Agent's Address], as my substitute Attorney-in-Fact, with the same authority and obligations as the primary Agent.
IV. RELIANCE ON THIS POWER OF ATTORNEY
Any healthcare provider, institution, or other person who acts in good faith reliance on the authority granted in this document shall be fully protected from any liability that might otherwise result from such actions.
V. REVOCATION
I reserve the right to revoke this Power of Attorney for Healthcare Decisions at any time, provided that such revocation is made in writing and delivered to my Attorney-in-Fact and all relevant healthcare providers.
VI. SEVERABILITY
If any provision of this Power of Attorney for Healthcare Decisions is held to be invalid or unenforceable, the remaining provisions shall nevertheless continue in full force and effect.
IN WITNESS WHEREOF, I have executed this Power of Attorney for Healthcare Decisions on this [Day] day of [Month, Year].
Principal:
[YOUR NAME]
Agent:
[AGENT'S NAME]
Witness Acknowledgement
We, the undersigned witnesses, affirm that the parties signing this New Jersey Power Of Attorney appeared before us, declared that they understood the contents of the document, and signed it willingly in our presence.
Witness 1:
[WITNESS 1 FULL NAME]
[DATE]
Witness 2:
[WITNESS 2 FULL NAME]
[DATE]
Notary Acknowledgement
State of New Jersey
On this _____ day of _____ before me, a Notary Public in and for said state, personally appeared [Your Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he/she executed the same for the purposes therein contained.
Witness my hand and official seal.
[NOTARY PUBLIC'S NAME]
My Commission Expires:
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