Living Wills English

New Mexico Living Will AND/OR New Mexico Durable Power of Attorney

(In compliance with the Patient Self-determination Act 1990)

Patient Self-determination Information Verification

1. Do you have a LIVING WILL (Right to Die) document? *

Yes

No

2. Do you have a DURABLE POWER of ATTORNEY for Health Care Decisions? *

Yes

No

If yes, complete the following information:

Where is it located? *

Information on Individual with Durable Power of Attorney and/or Living Will for
Health Care Decisions:

Name *

Phone: *

Address: *

City: *

State *

Zip *

Email Address *

If yes, place a copy of LIVING WILL (Right to Die) and/or DURABLE POWER of ATTORNEY for healthcare decisions in medical record.

Date copy requested:

Information obtained from:

Relationship to Patient:

If no, information concerning advance medical directives, including information describing the DURABLE POWER of ATTORNEY and LIVING WILLS has been given to this patient.

Patient Signature *

Date *

Staff Signature *

Date *

New Mexico Living Will AND/OR New Mexico Durable Power of Attorney

Quick Links

Recent News

Contact Us