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

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

"*" indicates required fields

Patient Self-determination Information Verification
1. Do you have a LIVING WILL (Right to Die) document?*
2. Do you have a DURABLE POWER of ATTORNEY for Health Care Decisions?*
If yes, complete the following information
Information on Individual with Durable Power of Attorney and/or Living Will for Health Care Decisions
If yes, place a copy of LIVING WILL (Right to Die) and/or DURABLE POWER of ATTORNEY for healthcare decisions in medical record.
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If no, information concerning advance medical directives, including information describing the DURABLE POWER of ATTORNEY and LIVING WILLS has been given to this patient.
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