Fillable Printable Health Care Proxy Form - New York
Fillable Printable Health Care Proxy Form - New York
Health Care Proxy Form - New York
Health Care Proxy
Appointing Your Health Care Agent
in New York State
The New York Health Care Proxy Law allows you to appoint
someone you trust — for example, a family member or close
friend – to make health care decisions for you if you lose the
ability to make decisions yourself. By appointing a health
care agent, you can make sure that health care providers
follow your wishes. Your agent can also decide how your
wishes apply as your medical condition changes. Hospitals,
doctors and other health care providers must follow your
agent’s decisions as if they were your own. You may give
the person you select as your health care agent as little or
as much authority as you want. You may allow your agent
to make all health care decisions or only certain ones. You
may also give your agent instructions that he or she has to
follow. This form can also be used to document your wishes
or instructions with regard to organ and/or tissue donation.
About the Health Care Proxy Form
This is an important legal document.
Before signing, you should understand the
following facts:
1. 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. “Health
care” means any treatment, service or
procedure to diagnose or treat your physical or
mental condition.
2. Unless your agent reasonably knows your
wishes about artificial nutrition and hydration
(nourishment and water provided by a feeding
tube or intravenous line), he or she will not be
allowed to refuse or consent to those measures
for you.
3. Your agent will start making decisions for you
when your doctor determines that you are not
able to make health care decisions for yourself.
4. 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. Your agent must follow your
instructions when making decisions for you.
5. You do not need a lawyer to fill out this form.
6. 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.
7. 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.
Tell the person you choose that he or she will
be your health care agent. Discuss your health
care wishes and this form with your agent. Be
sure to give him or her a signed copy. Your
agent cannot be sued for health care decisions
made in good faith.
8. If you have named your spouse as your health
care agent and you later become divorced
or legally separated, your former spouse can
no longer be your agent by law, unless you
state otherwise. If you would like your former
spouse to remain your agent, you may note
this on your current form and date it or
complete a new form naming your former
spouse.
9. Even though you have signed this form, you
have the right to make health care decisions
for yourself as long as you are able to do so,
and treatment cannot be given to you or
stopped if you object, nor will your agent have
any power to object.
10. You may cancel the authority given to your
agent by telling him or her or your health care
provider orally or in writing.
11. Appointing a health care agent is voluntary.
No one can require you to appoint one.
12. You may express your wishes or instructions
regarding organ and/or tissue donation on
this form.
Frequently Asked Questions
Why should I choose a health care agent?
If you become unable, even temporarily, to make
health care decisions, someone else must decide
for you. Health care providers often look to family
members for guidance. Family members may
express what they think your wishes are related to
a particular treatment. Appointing an agent lets
you control your medical treatment by:
•allowing your agent to make health care
decisions on your behalf as you would want
them decided;
•choosing one person to make health care
decisions because you think that person would
make the best decisions;
•choosing one person to avoid conict or
confusion among family members and/or
significant others.
You may also appoint an alternate agent to take
over if your first choice cannot make decisions
for you.
Who can be a health care agent?
Anyone 18 years of age or older can be a health
care agent. The person you are appointing as your
agent or your alternate agent cannot sign as a
witness on your Health Care Proxy form.
How do I appoint a health care agent?
All competent adults, 18 years of age or older,
can appoint a health care agent by signing a form
called a Health Care Proxy. You don’t need a lawyer
or a notary, just two adult witnesses. Your agent
cannot sign as a witness. You can use the form
printed here, but you don’t have to use this form.
When would my health care agent begin to
make health care decisions for me?
Your health care agent would begin to make
health care decisions after your doctor decides that
you are not able to make your own health care
decisions. As long as you are able to make health
care decisions for yourself, you will have the right
to do so.
What decisions can my health care
agent make?
Unless you limit your health care agent’s authority,
your agent will be able to make any health care
decision that you could have made if you were
able to decide for yourself. Your agent can agree
that you should receive treatment, choose among
different treatments and decide that treatments
should not be provided, in accordance with your
wishes and interests. However, your agent can
only make decisions about artificial nutrition
and hydration (nourishment and water provided
by feeding tube or intravenous line) if he or she
knows your wishes from what you have said or
what you have written. The Health Care Proxy
form does not give your agent the power to make
non-health care decisions for you, such as
financial decisions.
Why do I need to appoint a health care agent
if I’m young and healthy?
Appointing a health care agent is a good idea
even though you are not elderly or terminally ill.
A health care agent can act on your behalf if you
become even temporarily unable to make your
own health care decisions (such as might occur if
you are under general anesthesia or have become
comatose because of an accident). When you
again become able to make your own health care
decisions, your health care agent will no longer be
authorized to act.
How will my health care agent
make decisions?
Your agent must follow your wishes, as well as
your moral and religious beliefs. You may write
instructions on your Health Care Proxy form or
simply discuss them with your agent.
How will my health care agent know
my wishes?
Having an open and frank discussion about your
wishes with your health care agent will put him or
her in a better position to serve your interests. If
your agent does not know your wishes or beliefs,
your agent is legally required to act in your best
interest. Because this is a major responsibility for
the person you appoint as your health care
Frequently Asked Questions, continued
agent, you should have a discussion with the
person about what types of treatments you
would or would not want under different types of
circumstances, such as:
•whether you would want life support initiated/
continued/removed if you are in a permanent
coma;
•whether you would want treatments initiated/
continued/removed if you have a terminal
illness;
•whether you would want articial nutrition
and hydration initiated/withheld or continued
or withdrawn and under what types of
circumstances.
Can my health care agent overrule my
wishes or prior treatment instructions?
No. Your agent is obligated to make decisions
based on your wishes. If you clearly expressed
particular wishes, or gave particular treatment
instructions, your agent has a duty to follow those
wishes or instructions unless he or she has a good
faith basis for believing that your wishes changed
or do not apply to the circumstances.
Who will pay attention to my agent?
All hospitals, nursing homes, doctors and other
health care providers are legally required to
provide your health care agent with the same
information that would be provided to you and to
honor the decisions by your agent as if they were
made by you. If a hospital or nursing home objects
to some treatment options (such as removing
certain treatment) they must tell you or your
agent BEFORE or upon admission, if reasonably
possible.
What if my health care agent is not
available when decisions must be made?
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.
Otherwise, health care providers will make health
care decisions for you that follow instructions
you gave while you were still able to do so. Any
instructions that you write on your Health Care
Proxy form will guide health care providers under
these circumstances.
What if I change my mind?
It is easy to cancel your Health Care Proxy, to
change the person you have chosen as your
health care agent or to change any instructions
or limitations you have included on the form.
Simply fill out a new form. 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.
If you choose your spouse as your health care
agent or as your alternate, and you get divorced or
legally separated, the appointment is automatically
cancelled. However, if you would like your former
spouse to remain your agent, you may note this on
your current form and date it or complete a new
form naming your former spouse.
Can my health care agent be legally liable
for decisions made on my behalf?
No. Your health care agent will not be liable for
health care decisions made in good faith on your
behalf. Also, he or she cannot be held liable for
costs of your care, just because he or she is your
agent.
Is a Health Care Proxy the same as a
living will?
No. A living will is a document that provides
specific instructions about health care decisions.
You may put such instructions on your Health
Care Proxy form. The Health Care Proxy allows
you to choose someone you trust to make health
care decisions on your behalf. Unlike a living will,
a Health Care Proxy does not require that you
know in advance all the decisions that may arise.
Instead, your health care agent can interpret your
wishes as medical circumstances change and can
make decisions you could not have known would
have to be made.
Where should I keep my Health Care Proxy
form after it is signed?
Give a copy to your agent, your doctor, your
attorney and any other family members or close
friends you want. Keep a copy in your wallet or
purse or with other important papers, but not in
a location where no one can access it, like a safe
Frequently Asked Questions, continued
deposit box. Bring a copy if you are admitted to the
hospital, even for minor surgery, or if you undergo
outpatient surgery.
May I use the Health Care Proxy form to
express my wishes about organ and/or
tissue donation?
Yes. Use the optional organ and tissue donation
section on the Health Care Proxy form and be sure
to have the section witnessed by two people. You
may specify that your organs and/or tissues be
used for transplantation, research or educational
purposes. Any limitation(s) associated with your
wishes should be noted in this section of the proxy.
Failure to include your wishes and instructions
on your Health Care Proxy form will not be taken
to mean that you do not want to be an organ and/
or tissue donor.
Can my health care agent make decisions
for me about organ and/or tissue donation?
Yes. As of August 26, 2009, your health care agent
is authorized to make decisions after your death,
but only those regarding organ and/or tissue
donation. Your health care agent must make
such decisions as noted on your Health Care
Proxy form.
Who can consent to a donation if I choose
not to state my wishes at this time?
It is important to note your wishes about organ
and/or tissue donation to your health care agent,
the person designated as your decedent’s agent, if
one has been appointed, and your family members.
New York Law provides a list of individuals who
are authorized to consent to organ and/or tissue
donation on your behalf. They are listed in order
of priority: your health care agent; your decedent’s
agent; your spouse, if you are not legally separated,
or your domestic partner; a son or daughter 18
years of age or older; either of your parents; a
brother or sister 18 years of age or older; or a
guardian appointed by a court prior to the
donor’s death.
Health Care Proxy Form Instructions
Item (1)
Write the name, home address and telephone
number of the person you are selecting as your
agent.
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.
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.
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.
If you want to give your agent broad authority, you
may do so right on the form. Simply write: I have
discussed my wishes with my health care agent and
alternate and they know my wishes including those
about artificial nutrition and hydration.
If you wish to make more specific instructions, you
could say:
If I become terminally ill, I do/don’t want to receive
the following types of treatments....
If I am in a coma or have little conscious
understanding, with no hope of recovery, then I do/
don’t want the following types of treatments:....
If I have brain damage or a brain disease that
makes me unable to recognize people or speak and
there is no hope that my condition will improve, I
do/don’t want the following types of treatments:....
I have discussed with my agent my wishes
about____________ and I want my agent to make
all decisions about these measures.
Examples of medical treatments about which you
may wish to give your agent special instructions
are listed below. This is not a complete list:
• articial respiration
• articial nutrition and hydration
(nourishment and water provided by feeding
tube)
• cardiopulmonary resuscitation (CPR)
• antipsychotic medication
• electric shock therapy
• antibiotics
• surgical procedures
• dialysis
• transplantation
• blood transfusions
• abortion
• sterilization
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
and /or tissue donation on this form. New York
law does provide for certain individuals in order
of priority to consent to an organ and/or tissue
donation on your behalf: your health care agent,
your decedent’s agent, your spouse , if you are
not legally separated, or your domestic partner, a
son or daughter 18 years of age or older, either of
your parents, a brother or sister 18 years of age or
older, a guardian appointed by a court prior to the
donor’s death.
Item (7)
Two witnesses 18 years of age or older must sign
this Health Care Proxy form. The person who is
appointed your agent or alternate agent cannot
sign as a witness.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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 ____________________________________
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