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
1. General medical decisions
a. Provide or withhold consent to any medical procedure, tests or treatments including
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
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
b. Request, receive and review any information, oral or written, about my mental or
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
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
AS TO Client
STATE OF NEW JERSEY )
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