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

If yes, complete the following information:

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

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