New York Health Care Proxy

This form gives the person you choose as your agent the authority to make all health care decisions for you, including the decision to remove or provide life-sustaining treatment, unless you say otherwise in this form.

The Health Care Proxy form does not give your agent the power to make non-health care decisions for you, such as financial decisions.

Item (1): write the name, home address and telephone number of the person you are selecting as your agent.

Write the Proxy Name, then the Proxy Address lines (name, home address and telephone number) after hereby appoint.

Your health care agent can make any and all health care decisions for you, except to the extent that you state otherwise.

Your agent will start making decisions for you when your doctor determines that you are not able to make health care decisions for yourself.

You may choose any adult (18 years of age or older), including a family member or close friend, to be your agent.

If you select a doctor as your agent, he or she will have to choose between acting as your agent or as your attending doctor because a doctor cannot do both at the same time.

Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. Ask staff at the facility to explain those restrictions.

Before appointing someone as your health care agent, discuss it with him or her to make sure that he or she is willing to act as your agent.

Be sure to give him or her a signed copy.

Item (2) If you want to appoint an alternate agent, write the name, home address and telephone number of the person you are selecting as your alternate agent.

If the person you appoint is unable, unwilling or unavailable to act as your health care agent, you hereby appoint (name, home address and telephone number) as your health care agent to make any and all health care decisions for you, except to the extent that you state otherwise.

Item (3) Your Health Care Proxy will remain valid indefinitely unless you set an expiration date or condition for its expiration.

This section is optional and should be filled in only if you want your Health Care Proxy to expire.

You may write on this form examples of the types of treatments that you would not desire and/ or those treatments that you want to make sure you receive. The instructions may be used to limit the decision-making power of the agent.

Item (4) If you have special instructions for your agent, write them here. Also, if you wish to limit your agent's authority in any way, you may say so here or discuss them with your health care agent.

If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decision to consent to or refuse life-sustaining treatment.

You direct your health care agent to make health care decisions in accordance with the following limitations and/or instructions (attach additional pages as necessary).

In order for your agent to make health care decisions for you about artificial nutrition and hydration (nourishment and water provided by feeding tube and intravenous line), your agent must reasonably know your wishes. You can either tell your agent what your wishes are or include them in this section.

Your agent must follow your instructions when making decisions for you.

Item (5): you must date and sign this Health Care Proxy form.

If you are unable to sign yourself, you may direct someone else to sign in your presence.

Be sure to include your address.

Item (6) You may state wishes or instructions about organ, eye and /or tissue donation on this form.

Check any that apply to make an anatomical gift, to be effective upon your death: any needed organs, eyes and/or tissues; the following organs, eyes and/or tissues; or limitations.

Use the optional organ, eye and/or tissue donation section on the Health Care Proxy form and be sure to have the section witnessed by two people.

Any limitation(s) associated with your wishes should be noted in this section of the proxy.

If you do not state your wishes or instructions about organ, eye and/or tissue donation on this form, it will not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.

Item (7) Two witnesses 18 years of age or older must sign this Health Care Proxy form.

You don't need a lawyer or a notary, just two adult witnesses.

The person who is appointed your agent or alternate agent cannot sign as a witness.

“I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence.”

In addition, you may indicate that your Health Care Proxy expires on a specified date or if certain events occur. Otherwise, the Health Care Proxy will be valid indefinitely.

You may appoint an alternate agent to decide for you if your health care agent is unavailable, unable or unwilling to act when decisions must be made.