Health Care Proxy - New York Department Of Health

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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.

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