"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;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download "Health Care Proxy Form" - New York

200 times
Rate (4.5 / 5) 6 votes
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.
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.
(5) Your Identification (please print)
Your Name ___________________________________________________________________________
Your Signature _________________________________________________ Date ________________
Your Address __________________________________________________________________________
(6) Optional: Organ and/or Tissue Donation
I hereby make an anatomical gift, to be effective upon my death, of:
(check any that apply)
Any needed organs and/or tissues
The following organs and/or tissues ____________________________________________________
___________________________________________________________________________________
Limitations ________________________________________________________________________
If you do not state your wishes or instructions about organ 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.
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 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.
Date ____________________________________ Date _______________________________________
Name of Witness 1
Name of Witness 2
(print) __________________________________ (print) _____________________________________
Signature _______________________________ Signature __________________________________
Address _________________________________ Address ____________________________________
________________________________________ ___________________________________________
1430
7/12
Page of 2