Form F-190 - Health Care Proxy Form printable pdf download

ROSWELL PARK

CANCER INSTITUTE

ELM & CARLTON STREETS

F00190

BUFFALO, NY 14263

Health Care Proxy

1. I choose

_____________________________________________________________________________________________________________,

NAME OF HEALTH CARE AGENT

HOME ADDRESS

TELEPHONE NUMBER

to be my Health Care Agent to make health care decisions for me, if I become unable to make my own health care decisions.

2. OPTIONAL: ALTERNATE AGENT: If the person named above is unable, unwilling or unavailable to act as my health care agent, I choose:

________________________________________________________________________________________________________

NAME OF ALTERNATE AGENT

HOME ADDRESS

TELEPHONE NUMBER

3. Unless I revoke or cancel this proxy, it shall remain in effect indefinitely.

4. I direct my health care agent to make health care decisions according to my wishes and/or as stated below. My agent knows my wishes,

including those about artificial nutrition and hydration [nourishment and water provided by feeding tube and intravenous line], or my wishes

are described below.

_________________________________________________________________________________________________________

5. OPTIONAL: ORGAN AND /OR TISSUE DONATION:

I hereby, make an anatomical gift, to be effective upon my death, of:

Any needed organs

The Following organs and/or tissues:______________________________________________________________________

Limitations _________________________________________________________________________________________

I do not want to state my wishes about organ and/or tissue donation at this time.

If I do not state my wishes or instructions about organ and/or tissue donation on this form, it does not mean that I do not wish to

make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on my behalf.

My Signature: ______________________________________________________ Date: ______________________

My Name

: ____________________________________________________________________________

(please print)

My Address:____________________________________________________________________________________

TWO WITNESSES: (WITNESSES MUST BE 18 OR OLDER AND CANNOT BE THE HEALTH CARE AGENT OR ALTERNATE AGENT)

I declare that the person who signed this document is personally known to me and appears to be 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.

Witness #1:

Witness #2:

____________________________________________

_________________________________________________

Address:

_______________________________________________

___________________________________________________

Original - Patient

Copy - Medical Records

Copy - Registration

F-190 (Rev 03/09)

page 1 of 1

Form F-190 - Health Care Proxy Form

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