The New Jersey proxy directive form is a one-page document that lets you name a health care representative to make medical decisions for you if you ever lose the ability to make them yourself. You can download it free from the New Jersey Department of Health, fill it in by hand, and make it legally binding by signing it in front of two adult witnesses or a notary. No attorney is required, and there is no filing fee or state registry.
If you want to also record specific treatment wishes (a living will), that is a separate document called an instruction directive. Many people complete both, but the proxy directive alone gives your representative full legal authority over your health care decisions.1New Jersey Department of Health. Advance Directive – What Is Advance Directive?
Where to Get the Form
The official proxy directive is available as a downloadable PDF on the New Jersey Department of Health’s advance directive page.2New Jersey Department of Health. Advance Directive – Forms and FAQs Print it at home and complete it by hand. Hospitals in New Jersey also keep copies on hand for patients. The state-provided version already contains the language New Jersey statutes require, so it’s the safest one to use.
Who Can Sign One
You must be at least 18 years old and have the mental capacity to understand what the document does. The statute defines a “declarant” as an adult with the mental capacity to execute an advance directive.3Justia. New Jersey Code 26:2H-53 – Short Title You also have to sign voluntarily. Coercing or fraudulently inducing someone to sign an advance directive is a fourth-degree crime in New Jersey.4Justia. New Jersey Code 26:2H-78 – Violations, Penalties
Filling Out the Form Section by Section
The form is short, but every blank matters. Work through it in order.
Your Name and Primary Representative
Print your full legal name. Then fill in your health care representative’s full name, home address, and telephone number.5New Jersey Department of Health. New Jersey Proxy Directive Health Care Form By filling this in, you are granting that person authority to accept or refuse any treatment, service, or procedure used to diagnose or treat a physical or mental condition, including decisions about life-sustaining measures.
Pick someone you trust deeply and who understands your values around medical care. Talk with them before you write their name down. A representative who is caught off guard in a hospital hallway is a representative who may hesitate at the wrong moment.
Alternate Representatives
The form has a section for alternates, listed in priority order. If your primary representative is unavailable, unwilling, or unable to serve when a decision needs to be made, the next person on your list steps in automatically.5New Jersey Department of Health. New Jersey Proxy Directive Health Care Form Skipping this section is a common mistake. Emergencies don’t wait for your first choice to answer the phone. Name at least one backup.
Artificial Nutrition and Fluids
The form asks you to initial one of two statements about whether your representative may direct that artificially provided fluids and nutrition, such as a feeding tube or IV, be withheld or withdrawn. One option authorizes this; the other explicitly forbids it and directs that artificial nutrition continue to preserve your life to the extent medically appropriate.5New Jersey Department of Health. New Jersey Proxy Directive Health Care Form This is the one place on the form where your own written choice overrides your representative’s later judgment. Read both statements carefully before initialing.
Additional Instructions
Below the artificial-nutrition question is a space for anything else you want to add. You can restrict your representative from consenting to specific procedures, require consultation with certain family members, or spell out treatment preferences for particular diagnoses. Leaving it blank gives your representative broad authority to make whatever decision they believe you would have made.
Signing to Make It Legally Valid
Filling in the blanks is not enough. New Jersey law requires a formal execution step, and you have two options. You only need one.6Justia. New Jersey Code 26:2H-56 – Advance Directive, Execution
Two Adult Witnesses
Sign and date the form in front of two adult witnesses. Both must attest that you appear to be of sound mind and are signing free of duress and undue influence. There is one critical restriction: no one you have named as a health care representative or alternate may serve as a witness.6Justia. New Jersey Code 26:2H-56 – Advance Directive, Execution Neighbors, coworkers, or friends not named in the document all work.
Notary or Other Authorized Official
Alternatively, sign and date the form and acknowledge it before a notary public, an attorney, or another official authorized to administer oaths.6Justia. New Jersey Code 26:2H-56 – Advance Directive, Execution This carries the same legal effect as the two-witness method. Banks, shipping stores, and many municipal offices have notaries on staff, and the fee is usually modest.
Giving Out Copies and Storing the Original
Once executed, get copies to everyone who might need it in a crisis:
- Your health care representative and alternates, so they can present it to medical staff.
- Your primary care physician, with a request to add it to your permanent medical record.
- Close family members, even those not named in the directive, so they know it exists.
- Any hospital or nursing home you enter, at admission.
New Jersey does not require you to file the form with a court or state registry.2New Jersey Department of Health. Advance Directive – Forms and FAQs Keep the original somewhere accessible, not a safe deposit box your representative can’t open on a weekend. A wallet card noting that a proxy directive exists and identifying your representative helps emergency responders find the right person quickly. Scanning the signed form and saving a copy on your phone is a practical backup.
When the Directive Takes Effect
Your representative has no authority over your care while you can still make decisions for yourself. The proxy directive activates only after it has been determined that you lack decision-making capacity.7Justia. New Jersey Code 26:2H-61 – Authority to Make Health Care Decisions That determination is a clinical judgment made by your attending physician. It is not the same as a court declaring you legally incompetent. If you regain capacity, for example after recovering from surgery, you resume making your own decisions and the representative’s authority pauses.
Once activated, your representative has the right to be informed of your medical condition, prognosis, and treatment options, and to give informed consent to or refuse health care on your behalf. The guiding principle under New Jersey law is that they make the decision you would have made if you could; when your wishes can’t be determined, they must act in your best interest. If a court later appoints a legal guardian for you, your health care representative still retains authority over medical decisions unless the court order specifically says otherwise.7Justia. New Jersey Code 26:2H-61 – Authority to Make Health Care Decisions Naming someone as your representative does not make them responsible for any of your health care costs.
Changing or Revoking Your Directive
You can revoke your proxy directive at any time, and it doesn’t require a lawyer or even a written document. New Jersey law allows revocation by simply telling your representative, doctor, nurse, or any reliable witness that you want to cancel it, or by any other act that shows you intend to revoke.8Justia. New Jersey Code 26:2H-57 – Proxy Directive, Modification, Revocation You can also revoke it by signing a new proxy directive that replaces the old one, following the same execution requirements.
To modify the directive rather than replace it, the change must follow the same signing requirements as the original.8Justia. New Jersey Code 26:2H-57 – Proxy Directive, Modification, Revocation Most people find it easier to complete a fresh form and destroy the old one.
One automatic revocation to know about: if you named your spouse as your representative and later divorce or legally separate, that designation is automatically revoked. The same applies if you named a domestic partner or civil union partner and the relationship is formally terminated.8Justia. New Jersey Code 26:2H-57 – Proxy Directive, Modification, Revocation Unless your directive specifically says the designation survives the breakup, you will need to complete a new form naming a different representative.