The Rabbinical Council Of America - Halachic Health Care Proxy (Page 4 of 6) in pdf

Telephone/Email:

Office___________________________

Home __________________________________

Cell ____________________________

E-mail: _________________________________

If such Orthodox Rabbi is unable, unwilling or unavailable

to consult with the following Orthodox Rabbi and I ask my

to provide such consultation and guidance, I direct my agent

agent to comply with his halachic decisions:

Alternate Rabbi

Name_______________________________________________________________________

Address ____________________________________________________________________

Telephone/Email:

Office___________________________

Home __________________________________

Cell ____________________________

E-mail: _________________________________

4. Direction to Health Care Providers: Any health care

Orthodox interpretation and tradition. For example, Jewish

provider shall rely upon and carry out the decisions of my

law generally requires expeditious burial and imposes

agent, and may assume that such decisions reflect my wishes

special requirements with regard to the preparation of the

and were arrived at in accordance with the procedures set

body for burial. It is my wish that Jewish law and custom be

forth in this directive, unless such health care provider shall

followed with respect to these matters.

have good cause to believe that my agent has not acted in

good faith in accordance with my wishes as expressed in this

Further, subject to certain limited exceptions, Jewish law

directive.

generally prohibits the performance of any autopsy or

dissection. It is my wish that Jewish law and custom be

If the persons designated in section 1 above as my agent and

followed with respect to such procedures, and with respect

alternate agent are unable, unwilling or unavailable to serve

to all other post-mortem matters including the removal and

in such capacity, it is my desire, and I hereby direct, that any

usage of any of my body organs or tissue for transplantation

health care provider or other person who will be making

or any other purposes. I direct that any health care provider

health care decisions on my behalf follow the procedures

in attendance at my death notify the agent and/or Orthodox

outlined in section 3 above in determining the requirements

Rabbi described above immediately upon my death, in

of Jewish law and custom.

addition to any other person whose consent by law must be

solicited and obtained, prior to the use of any part of my

Pending contact with the agent and/or Orthodox Rabbi

body as an anatomical gift, so that appropriate decisions and

described above, it is my desire, and I hereby direct, that all

arrangements can be made in accordance with my wishes.

health care providers undertake all essential emergency

Pending such notification, and unless there is specific

and/or life sustaining measures on my behalf.

authorization by the Orthodox Rabbi consulted in

accordance with the procedures outlined in section 3 above,

5. Access to Medical Records and Information; HIPAA:

it is my desire, and I hereby direct, that no post-mortem

My agent(s) and Rabbi(s) are hereby authorized under the

procedure be performed on my body.

Health Insurance Portability and Accountability Act of 1996

(“HIPAA”) access to any and all protected information, and

7. Incontrovertible Evidence of My Wishes: If, for any

accordingly all of my protected health information (as such

reason, this document is deemed not legally effective as a

term is defined under HIPAA) and other medical records

health care proxy, or if the persons designated in section 1

shall be made available to my agent and rabbi upon request

above as my agent and alternate agent are unable, unwilling

in the same manner as such information and records would

or unavailable to serve in such capacity, I declare to my

be released and disclosed to me, and my agent and rabbi

family, my doctor and anyone else whom it may concern

shall have and may exercise all of the rights I would have

that the wishes I have expressed herein with regard to

regarding the use and disclosure of such information and

compliance with Jewish law and custom should be treated as

records, as required under HIPAA.

incontrovertible evidence of my intent and desire with

respect to all health care measures and post-mortem

6. Post-Mortem Decisions: It is also my desire, and I

procedures; and that it is my wish that the procedure

hereby direct, that after my death, all decisions concerning

outlined in section 3 above should be followed in

the handling and disposition of my body be made pursuant

determining the requirements of Jewish law and custom.

to Jewish law and custom as determined in accordance with

The Rabbinical Council Of America - Halachic Health Care Proxy Page 4

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