Combined Advance Directive for Health Care, New Jersey

NEW JERSEY

COMBINED ADVANCE DIRECTIVE FOR HEALTH CARE

(Combined Proxy and Instruction Directive)

I understand that as a competent adult I have the right to make decisions about my health care.  There may come a time when I am unable, due to physical or mental incapacity, to make my own health care decisions.  In these circumstances, those caring for me will need direction and they will turn to someone who knows my values and health care wishes.  By writing this durable power of attorney for health care, I appoint a health care representative with the legal authority to make health care decisions on my behalf and to consult with my physician and others.  I direct that this document become part of my permanent medical records.

In completing Part One of this directive, you will designate an individual you trust to act as your legally recognized health care representative to make health care decisions for you in the event that you are unable to make decisions for yourself.

In completing Part Two of this directive, you will provide instructions concerning your health care preferences and wishes to your health care representative and others who will be entrusted with responsibility for your care, such as your physician, family members, and friends.

PART ONE.  DESIGNATION OF HEALTH CARE REPRESENTATIVE

1. CHOOSING A HEALTH CARE REPRESENTATIVE

I hereby designate:

Name              __________________________

Address           __________________________

                        __________________________

Telephone       __________________________