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.

Form NameNy Health Proxy Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other nameshealth care proxy form ny, nys health care proxy form, new york state health care proxy form, ny state proxy form

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:




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):












Name of Witness 2 (please print):








Address :




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Step 1: The first step requires you to click the orange "Get Form Now" button.

Step 2: Once you've accessed the editing page ny health care proxy form, you'll be able to see all of the functions readily available for the document inside the upper menu.

Please provide the following information to fill out the ny health care proxy form PDF:

part 1 to writing health care proxy

Inside the segment If the person I appoint is unable, Alternates Name, Alternates Home Address, Alternates Telephone Numbers, Unless I revoke it this proxy, and Optional Instructions I direct my type in the data the program requires you to do.

Filling in health care proxy part 2

You will need to include certain data in the section Optional Instructions I direct my, and My agent knows my wishes regarding.

health care proxy Optional Instructions I direct my, and My agent knows my wishes regarding blanks to fill out

The Your Identification please print, Your Name, Your Signature, Your Address, Date, Optional Organ andor Tissue, Upon my death I wish to donate my, Any needed organs andor tissues, Only the following organs andor, My donation is for the following, and transplant therapy research area needs to be used to note the rights or responsibilities of both sides.

Completing health care proxy step 4

Prepare the document by checking all these areas: transplant therapy research, Your Signature Date, Statement by Witnesses Witnesses, cannot be the health care agent or, I declare that the person who, Name of Witness please print, Signature, Address, Name of Witness please print, Date, and Date.

part 5 to completing health care proxy

Step 3: Press the "Done" button. So now, you can transfer your PDF document - save it to your electronic device or deliver it by means of electronic mail.

Step 4: Just be sure to generate as many copies of your file as you can to keep away from future misunderstandings.

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