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Fillable Printable New York State Health Care Proxy Form

Fillable Printable New York State Health Care Proxy Form

New York State Health Care Proxy Form

New York State Health Care Proxy Form

New York State Health Care Proxy Form
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 when and if I become unable to make my own
health care decisions.
2. Optional instructions: I direct my agent to make health care decisions in accord with my wishes and
limitations as stated below, or as he or she otherwise knows. (Attach additional pages if
necessary.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Unless your agent knows your wishes about artificial nutrition and hydration (feeding tubes),
your agent will not be allowed to make decisions about artificial nutrition and hydration.
See instructions on reverse for samples of language you could use.)
3. Name of substitute or fill-in-agent if the person I appoint above is unable, unwilling or
unavailable to act as my health care agent.
______________________________________________________________________________
(name, home address and telephone number)
______________________________________________________________________________
4. Unless I revoke it, this proxy shall remain in effect indefinitely, or until the date or conditions
stated below. This proxy shall expire (specific date or conditions, if desired):
______________________________________________________________________________
5. Signature ___________________________________________________________________
Address ______________________________________________________________________
Date_________________________________________________________________________
Statement by Witnesses (must be 18 or older)
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.
Witness 1 _____________________________________________________________________
Address ______________________________________________________________________
Witness 2 _____________________________________________________________________
Address_______________________________________________________________________
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