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"Health Care Proxy Form" - New York

Health Care Proxy Form is a legal document that was released by the New York State Department of Health - a government authority operating within New York.

Form Details:

Released on July 1, 2012;
The latest edition currently provided by the New York State Department of Health;
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Health Care Proxy

(1) I, ___________________________________________________________________________________

hereby appoint ________________________________________________________________________

(name, home address and telephone number)

_____________________________________________________________________________________

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 Agent

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

appoint _____________________________________________________________________________

(name, home address and telephone number)

_____________________________________________________________________________________

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

state otherwise.

(3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall

remain in effect indeﬁnitely. (Optional: If you want this proxy to expire, state the date or conditions

here.) This proxy shall expire (specify date or conditions): _____________________________________

_____________________________________________________________________________________

(4) Optional: I direct my health care agent to make health care decisions according to my wishes and

limitations, as he or she knows or as stated below. (If you want to limit your agent’s authority to make

health care decisions for you or to give speciﬁc instructions, you may state your wishes or limitations

here.) I direct my 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.

See instructions for sample language that you could use if you choose to include your wishes on this

form, including your wishes about artiﬁcial nutrition and hydration.