Ny Health Proxy Form PDF Details

Ny health proxy form is a document that allows you to appoint a person to make decisions about your health care if you are unable to do so. The form is also known as advance directive or living will. It gives you the opportunity to express your wishes regarding medical treatment and end-of-life care. Completing the form can help ensure that your wishes are followed if you become unable to make decisions yourself. You can find the form on the website of New York State Department of Health.

The following are some particulars about ny health proxy form. You might want to go through it before submitting the gaps.

QuestionAnswer
Form NameNy Health Proxy Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesny state health care proxy, health care proxy ny, ny health care form, new york state health care proxy

Form Preview Example

New York Health Care Proxy

(1) I, _____________________________________________________, hereby appoint:

Agent’s Name:

Agent’s Home Address:

Agent’s Telephone Numbers:

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.

This proxy shall take effect only when and if I become unable to make my own health care decisions.

(2) Optional: Alternate

If the person I appoint is unable, unwilling or unavailable to act as my health care agent, I hereby appoint:

Alternate’s Name:

Alternate’s Home Address:

Alternate’s Telephone Numbers:

(3) Unless I revoke it, this proxy shall remain in effect indefinitely or until the date or condition I have stated below. (Optional: If you want this proxy to expire, state the date or conditions here.) This proxy will expire (specify date or conditions):

(4) Optional Instructions: I direct my agent to make health decisions in accordance with my wishes and limitations as stated below, or as he or she otherwise knows. (attach additional pages as necessary)

My agent knows my wishes regarding artificial nutrition and hydration.

(5) Your Identification (please print)

Your Name:

Your Signature:

Date:

 

 

Your Address:

(6) Optional: Organ and/or Tissue Donation

Upon my death, I wish to donate my organs, tissues or body parts: (check any that apply and note limitations)

Any needed organs and/or tissues

_____ Only the following organs and/or tissues:

My donation is for the following:

___transplant ___therapy ___research ___education ___any use

Your Signature: ______________________________________ Date:________________

(7) Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the health care agent or alternate.)

I declare that the person who signed this document is known to me and appears to execute this proxy willingly and 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.

Name of Witness 1 (please print):

Date:

 

 

Signature:

 

 

 

Address:

 

 

 

Name of Witness 2 (please print):

Date:

 

 

Signature:

 

 

 

Address :

 

 

 

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