Application For Admission To The New York Armenian Home (Page 8 of 10) in pdf

About the Health Care Proxy

This is an important legal form. Before signing this form,

Talk about choosing an agent with your family and/or close

you should understand the following facts:

friends. You should discuss this form with a doctor or

another health care professional, such as a nurse or social

1. This form gives the person you choose as your agent the

worker, before you sign it to make sure that you understand

authority to make all health care decisions for you,

the types of decisions that may be made for you. You may

except to the extent you say otherwise in this form.

also wish to give your doctor a signed copy. You do not need

“Health care” means any treatment, service or procedure

a lawyer to fill out this form.

to diagnose or treat your physical or mental condition.

You can choose any adult (over 18), including a family

2. Unless you say otherwise, your agent will be allowed to

member, or close friend, to be your agent. If you select a

make all health care decisions for you, including

doctor as your agent, he or she may have to choose between

decisions

remove

withhold

life-sustaining

acting as you agent or as your attending doctor. A physician

treatment.

cannot do both at the home or mental hygienic facility; there

3. Unless your agent knows your wishes about artificial

are special restrictions about naming someone who works

nutrition and hydration (nourishment and water provided

for that facility as your agent. You should ask staff at the

by a deeding tube), he or she will not be allowed to

facility to explain those restrictions.

refuse those measures for you.

You should tell the person you choose that he or she will be

4. Your agent will start making decisions for you when

your health care agent. You should discuss your health care

doctors decide that you are not able to make health care

wishes and this form with your agent. Be sure to give him or

decisions for yourself.

her signed copy. You agent cannot be sued for health care

You may write on this form any information about treatment

decisions made in good faith.

that you do not desire and /or those treatments that you want

Even after you have signed this form, you have the right to

to make sure you receive. Your agent must follow your

make health care decisions for yourself as long as you are

instructions (oral and written) when making decisions for

able to do so, and treatment cannot be sued for health care

you.

decisions made in good faith.

If you want to give your agent written instructions, do so

Filling out the Proxy Form

right on the form. For example, you could say:

If I become terminally ill, I do/don’t want to receive

Item (1)

Write your name and the name, home

the following treatments…

address and telephone number of the person

If I am in a come or unconscious, with no hope or

you are selecting as your agent.

recovery, then I do/don’t want….

Item (2)

If you have special instruction for your

If I have brain damage or brain disease that makes

agent, you should write them hers. Also, if

me unable to recognize people or speak and there is

you wish to limit your agent’s authority in

no hope that my condition will improve. I do/don’t

any way, you should say so here. If you do

want….

not state any limitations, your agent will be

I have discussed with my agent my wishes

allowed to make all health care decisions

About--------------------------and I want my agent to

that you could have made, including the

make all decisions about these measures.

Examples of medical treatments about which you may wish

decision to consent to or refuse life-

to give your agent special instructions are listed below. This

sustaining treatment.

is not a complete list for the treatments about which you may

Item (3)

You may write the name, home address and

leave instructions.

telephone number of an alternate agent.



Artificial respiration

Item (4)

This form will remain valid indefinitely



Artificial nutrition and hydration (nourishment

unless you set an expiration date or

and water provided by deeding tube)

condition for its expiration. This section is



optional and should be filled in only if you

Cardiopulmonary resuscitation (CPR)

want the health care proxy to expire.



Antipsychotic medication

Item (5)

You must date and sign the proxy. If you are



Electric shock therapy

unable to sign yourself, you may direct



Dialysis

someone else to sign in you presence. Be



Transplantation

sure to include your address.



Blood transfusions

Two witnesses at least 18 years of age must sign your proxy.



Abortion

The person who is appointed agent or alternate agent cannot



Sterilization

Sign as a witness.

Application For Admission To The New York Armenian Home Page 8

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