New York State Health Care Proxy Form printable pdf download

New York State Health Care Proxy Form

HEALTH CARE PROXY

Appointing Your Health Care Agent

in New York State

To Our Patients:

The New York Health Care Proxy Law allows you to appoint someone you trust – for example, a family

member or close friend – to make health care decisions for you if you lose the ability to make decisions

yourself. By appointing a health care agent, you can make sure that health care providers follow your wishes.

Your agent can also decide how your wishes apply as your medical condition changes. Hospitals, doctors and

other health care providers must follow your agent’s decisions as if they were your own. You may give the

person you select as your health care agent as little or as much authority as you want. You may allow your

agent to make all health care decisions or only certain ones. You may also give your agent instructions that he

or she has to follow.

To appoint a proxy, you should fill out the Health Care Proxy, on the reverse side of this form, sign it, date it,

and have two witnesses sign and date it. Your agent may not be a witness.

Your agent can be any adult who is over the age of 18 or a minor who has married or is the parent of a child.

If you should ever change your mind about the wishes stated in your proxy or about the person you have

designated to be your agent, you can revoke your proxy at any time to your health care providers or hospital

verbally or in writing.

You can name an alternative agent when you sign your proxy, so if your agent cannot be contacted, the

alternative agent can make decisions.

Talk to the person who is named as your agent, and give the agent a copy of the form. Give copies to your

doctors and to any hospital or nursing home in which you are a patient. Be prepared to show them the original

document. Tell family and those closest to you about the proxy and give them copies. Keep track of copies so

that you can inform all these individuals if you revoke the proxy or change agents.

WGCA Physicians

health care proxy.doc 4/29/05 dp

New York State Health Care Proxy Form