New Mexico Optional Advance Health Care Directive Form Page 1 of 5
New Mexico Optional Advance Health Care Directive Form
EXPLANATION FOR MEMBERS
You have the right to give instructions about your own health care. You also have the right to name
someone else to make health care decisions for you. This form lets you do either or both of these things. It
also lets you express your wishes regarding the designation of your primary physician.
THIS FORM IS OPTIONAL. Each paragraph and word of this form is also optional. If you use this form,
you may cross out, complete or modify all or any part of it. You are free to use a different form. If you
use this form, be sure to sign it and date it.
PART 1 of this form is a power of attorney for health care. PART 1 lets you name another individual as
agent to make health care decisions for you if you become incapable of making your own decisions or if
you want someone else to make those decisions for you now even though you are still capable. You may
also name an alternate agent to act for you if your first choice is not willing, able or reasonably available
to make decisions for you. Unless related to you, your agent may not be an owner, operator or employee
of a health care institution at which you are receiving care.
Unless the form you sign limits the authority of your agent, your agent may make all health care decisions
for you. This form has a place for you to limit the authority of your agent. You need not limit the
authority of your agent if you wish to rely on your agent for all health care decisions that may have to be
made. If you choose not to limit the authority of your agent, your agent will have the right to:
1. Consent or refuse consent to any care, treatment, service or procedure to maintain, diagnose or
otherwise affect a physical or mental condition;
2. Select or discharge health care providers and institutions;
3. Approve or disapprove diagnostic tests, surgical procedures, programs of medication and orders
not to resuscitate; and
4. Direct the provision, withholding or withdrawal of artificial nutrition and hydration and all other
forms of health care.
PART 2 of this form lets you give specific instructions about any aspect of your health care. Choices are
provided for you to express your wishes regarding life-sustaining treatment, including the provision of
artificial nutrition and hydration, as well as the provision of pain relief. In addition, you may express your
wishes regarding whether you want to make an anatomical gift of some or all of your organs and tissue.
Space is also provided for you to add to the choices you have made or for you to write out any additional
wishes.
PART 3 of this form lets you designate a physician to have primary responsibility for your health care.
After completing this form, sign and date the form at the end. It is recommended but not required that you
request two other individuals to sign as witnesses. Give a copy of the signed and completed form to your
physician, to any other health care providers you may have, to any health care institution at which you are
receiving care and to any health care agents you have named. You should talk to the person you have
named as agent to make sure that he or she understands your wishes and is willing to take the
responsibility.
You have the right to revoke this advance health care directive or replace this form at any time.
