Dental Health Care Proxy Template printable pdf download

EmblemHealth Family Dental Practice

Health Care Proxy

EmblemHealth Family Dental Practice

1873 Western Ave., Suite 200

Albany, NY 12203

(518) 869‐1044

Fax (518) 869‐1965

Health Care facilities such as EmblemHealth Family Dental Practice are required by New York State

Department of Health regulations to provide information about Advanced Directives to all of our adult

patients. Please read the paragraph below and then complete the form.

Appointing Your Health Care Agent in New York

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 conditions change. 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.

I, the undersigned, have read the material about Heath Care Proxies.

I would like to exercise the following option (please select only one)

[ ] Receive a copy of the New York State Health Care Proxy Form to complete

[ ] Provide a copy of an existing Health Care Proxy to EmblemHealth Family Dental Practice

[ ] I do not wish to complete a Health Care Proxy form at this time

Print Patient Name _________________________________________________________________________

Patient Signature _______________________________________________ Date _____________________

If signing for a minor, please indicate relationship to patient _______________________________________

Dental Health Care Proxy Template