Fillable Printable Health Care Proxy Form - New York City

Health Care Proxy Form - New York City

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 :