New Hampshire Advance Health Directive(Living Will) Form

The New Hampshire advance health directive(living will) is a legal document that is specifically designed to guide an individual (Principal) through the steps of creating a document that will outline the wishes of the Principal, in the even they are unable to no longer make their own health care decisions or are in a persistent vegetative state. The document will instruct the physicians and their health care agent as to how to implement the end of life treatment. The Principal may also elect a health care agent in this document, if they have not already done so. The document or any portion of it may be revoked at any time.

Laws – 137-H:1 et seq. Living Wills

How to Write

Step 1 – Durable Power of Attorney for Health Care – The Principal may appoint a health care agent here (optional) – Submit:

  • Enter the name of the Principal
  • Principal’s Date of Birth in mm/dd/yyyy format
  • AND
  • Enter the name of the health care agent
  • Read the Paragraph
  • Enter an alternate agent by providing:
  • Name of the alternate agent
  • Address and Telephone number
  • Review the remainder of this section

Step 2 – Life Sustaining Treatment – Principal must read the authorization statement:

  • Initial either A or B in 1 and 2, that would reflect the Principal’s wishes

Step 3 – Medically Administered Nutrition and Hydration – Read information before proceeding – If this section is left blank the health care provider will not have permission to authorize withholding of life sustaining treatment

  • Carefully consider and initial A or B in this section

Step 4 – Explanation of the Principals Instructions in More Detail –

  • Initial any or all of the statements that are applicable to the Principal’s wishes
  • If there are more specific instructions, the Principal may enter them in the lines provided
  • Once complete, Print the Principal’s name and Date of Birth in mm/dd/yyyy format at the end of all pages in the document

Step 5 – Disclosure – The Principal must read the statement  –

  • Enter the locations and persons who will have possession of a copy of this instrument
  • Date the Principal’s signature in dd/m/yy format
  • Principal’s Signature

Step 6 – Witness Signatures – The power of attorney must be be signed by two witnesses OR a notary or Justice of the Peace:

  • Witnesses must read and agree to the witness statement
  • If in agreement the witnesses must provide their respective signatures
  • Witnesses addresses
  • OR
  • If the Principal elects to use a notary or Justice, they shall witness the Principal’s information and acknowledge the signature

Step 7 – Living Will – Enter the date of execution in dd/m/yy format

  • Enter the Principal’s name
  • Select one statement, A or B and initial
  • The Principal must read the competency statement
  • Enter the date in dd/m/yy format
  • Submit the Principal’s signature or have someone do it for the Principal
  • AND
  • The witnesses must read the witness statement, if in agreement, enter:
  • The respective signatures of each witness
  • Complete address
  • OR
  • If using a notary or Justice of the Peace, they must witness the Principal’s signature and complete the remainder of the section in acknowledgement

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