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New Jersey Advance Directive Form

A New Jersey advance directive is a form that allows a resident of New Jersey to appoint someone else as a healthcare representative, who will make any and all healthcare decisions on their behalf. These include decisions to accept or refuse treatments, services, or procedures used to diagnose or treat physical and mental conditions and to provide, withhold, or withdraw life-sustaining treatment. The healthcare representative is also authorized by the form to make decisions that have not been outlined by the principal in advance.

Signing Requirements (§ 26:2H-56) – Two (2) witnesses or a notary public.

Sample

Durable Power of Attorney for Health Care for the Appointment of a Health Care Representative (Proxy Directive)

I [NAME] (print name here) do hereby appoint:

(Name) [NAME]
(City) [CITY]
(State) [STATE]
(Zip) [ZIP CODE]

to be my health care representative to make any and all health care decisions for me, including decisions to accept or to refuse any treatment, service or procedure used to diagnose or treat my physical or mental condition and decisions to provide, withhold or withdraw life-sustaining treatment if I am unable to make such decision myself. I direct my health care representative to make decisions on my behalf in accordance with my wishes as stated in this document, or as otherwise known to him or her. In the event my wishes are not clear or if a situation arises that I did not anticipate my health care representative is authorized to make decisions in my best interest. If the previously named person is unable, unwilling, or unavailable to act as my health care representative, I appoint the following as my alternate health care representative:

Name [NAME]
Telephone [PHONE NUMBER]
Address [STREET ADDRESS]
City [CITY]
State [STATE]
Zip Code [ZIP CODE]

I sign this document knowingly and after careful deliberation this [DAY] day of [MONTH], 20[XX].

Signature ___________________________________________________________
Address [STREET ADDRESS]
City [CITY]
State [STATE]
Zip Code [ZIP CODE]

Witnesses
Witness Signature ______________________________________________________
Witness Name (print) [NAME]
Address [STREET ADDRESS]
City [CITY]
State [STATE]
Zip Code [ZIP CODE]

Witness Signature ______________________________________________________
Witness Name (print) [NAME]
Address [STREET ADDRESS]
City [CITY]
State [STATE]
Zip Code [ZIP CODE]

Sworn and Subscribed before me on the [DAY] day of [MONTH], 20[XX].

___________________________________________________________________

Notary Public – State of New Jersey