'Medical Power of Attorney Form'

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					                                                                        For attorney use only
                              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 or withhold consent          for    psychological,   psychiatric,   behavioral   or
          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.
A Health Care Professional or Health Care Institution that relies in good faith on a consent or waiver
given under this Medical Power of Attorney shall incur no liability for any act or omission
undertaken at the direction of my Health Care Representative.

For purposes of identification, the signature of my Health Care Representative is as follows:


                                                        ____________________________________
                                                        Signature of HCR


This document has been explained to me and my Agent by________________________________.
I understand the content of this document and I voluntarily sign this statement.

IN WITNESS WHEREOF, I have hereunto set my hand and seal,______________________this day
of _________________________________.


WITNESS:


_____________________________                              ____________________________(L.S.)
                       AS TO                                Client


STATE OF NEW JERSEY )
                    )SS:
COUNTY OF ESSEX     )


BE IT REMEMBERED, that on this______day of ________, 2006, before me, an Attorney at Law
of the State of New Jersey, personally appeared___________________, who I am satisfied, is the
person mentioned in and who executed the within instrument and to whom I first made known the
contents thereof, and thereupon he/she acknowledged that he/she signed by his/her mark, sealed and
delivered the same as his/her voluntary act and deed for the uses and purposes therein expressed.


                                                        ____________________________________
                                                        Attorney at Law, State of New Jersey

This document has been explained to me by_______________________. I understand the content
of this document, and I voluntarily sign this statement. No one has forced me to do this.


                                                        ____________________________________
                                                        Signature of Client

				
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