New York State Health Care Proxy
- (1) I, __________________________________________, hereby appoint _________________________________ (tel.)___________________ Address________________
_______________________________________________ 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 _______
- 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 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 _____________________________ , 200 _____
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)
9 Any needed organs and/or tissues
9 The following organs and/or tissues ______________________________________________
9 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 ___________ , 200__
- (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.
________________, 200__ _________________, 200__
Name of Witness 1 Name of Witness 2
(print) ________________ (print) __________________
Signature ______________ Signature ________________
Address _______________ Address ________________
PLEASE READ INSTRUCTIONS FROM THE NEW YORK STATE DEPARTMENT OF HEALTH BEFORE COMPLETING
THE HEALTH CARE PROXY
DISTRIBUTED BY JAY J. SANGERMAN, PLLC
ATTORNEYS AT LAW
60 EAST 42ND STREET
NEW YORK, NEW YORK 10165
Offices located in New York, Florida and New Jersey
*Derived from the Health Care Proxy developed by the State of New York Department of Health.
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