The Rabbinical Council Of America - Halachic Health Care Proxy (Page 2 of 6) in pdf

Instructions

(a) Print your name on the first line of the form.

your behalf, as long as he or she does so at your direction, in

your presence, and in the presence of two adult witnesses.

(b) In Section 1, print the name, address, and telephone

numbers of the person you wish to designate as your agent

(e) In the Declaration of Witnesses section, two witnesses

to make medical decisions on your behalf if you ever

should sign their names and insert their addresses beneath

become incapable of making them on your own. Be sure to

your signature. These two witnesses must be competent

include all numbers (including cell phone and pager) where

adults. Neither of them should be the person you have

your agent can be reached in the event of an emergency. If

appointed as your health care agent (or alternate agent).

the contact information for your agent changes, you should

They may, however, be your relatives.

provide that updated information to everyone whom you

have provided with a copy of your Health Care Proxy.

If you reside in a mental health facility, at least one witness

must be an individual who is not affiliated with the facility.

You should also insert the name, address, and telephone

In addition, if the mental health facility is also a hospital, at

numbers of an alternate agent, to make such decisions if

least one witness must be a qualified psychiatrist.

your main agent is unable, unwilling, or unavailable to make

such decisions.

(f) It is recommended that you keep the original of this

form among your valuable papers in a location that is

Before appointing anyone to serve as your agent, or

readily accessible in the event of an emergency; and that

alternate agent, ascertain that person’s willingness to serve

you distribute copies to the health care agent (and alternate

in such capacity. For your convenience, an addendum at the

agent) you have designated in section 1, to the rabbi(s) you

end of this document provides talking points to facilitate

have designated in section 3, as well as to your doctors, your

discussion between you and your proxy. In addition, if you

lawyer, and anyone else who is likely to be contacted in

have made arrangements with a burial society (Chevra

times of emergency.

Kadisha) for the handling and disposition of your body after

death, you may wish to advise your agents of such

(g) If, at any time, you wish to revoke this Proxy and

arrangements.

Directive, you may do so by executing a new one; or by

notifying your agent or health care provider, in writing, of

Note: the law allows virtually any competent adult (an adult

your intent to revoke it. To avoid possible confusion, it

is a person 18 years of age or older, or anyone who has

would be wise to try to obtain all originals and copies of the

married) to serve as a health care agent. Thus, you may

old Proxy and Directive and destroy them.

appoint as your agent (or alternate agent) your spouse, adult

child, parent or other adult relative.

If you do not revoke the Proxy and Directive, the Law

provides that it remains in effect indefinitely. Obviously, if

You may also appoint a non-relative to serve as your agent

any of the persons whose names you have inserted in the

(or alternate agent), provided that individual has not already

Proxy and Directive dies or becomes otherwise incapable of

been appointed by 10 other persons to serve as a health care

serving in the role you have assigned, you should execute a

agent, or, is a non-physician employee of a health care

new Proxy and Directive.

facility in which you are a patient or resident.

(h) It is recommended that you also complete the

Emergency Instructions Card contained at the end of this

telephone numbers of the Orthodox rabbi and the alternate

form, and carry it with you in your wallet or purse.

Orthodox rabbi whose guidance you want your agent to

follow, should any questions arise as to the requirements of

(i) If, upon consultation with your rabbi, you would like to

halacha.

add to this standardized Proxy and Directive any additional

expression of your wishes with respect to medical and/or

You are free to insert the name of any Orthodox Rabbi(s)

post-mortem decisions, you may do so by attaching a

you choose. However, you are encouraged to discuss the

“rider” to the standardized form. If you choose to do so, or

matter with the rabbi to ascertain his specialization in end-

if you have any other questions concerning this form, please

of-life halachic issues and willingness to serve in such

consult an attorney.

capacity.

These instructions are not part of the Halachic Health Care

(d) In Section 8, sign and print your name, address, phone

Proxy and need not be kept attached to the executed

numbers, and the date. If you are not physically able to sign

document.

and date the form, the law allows another person to do so on

The Rabbinical Council Of America - Halachic Health Care Proxy Page 2

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