Health Care Proxy Form - New York

About the Health Care Proxy Form
This is an important legal document.
Before signing, you should understand the
following facts:
1. This form gives the person you choose as your
agent the authority to make all health care
decisions for you, including the decision to
remove or provide life-sustaining treatment,
unless you say otherwise in this form. “Health
care” means any treatment, service or
procedure to diagnose or treat your physical or
mental condition.
2. Unless your agent reasonably knows your
wishes about artificial nutrition and hydration
(nourishment and water provided by a feeding
tube or intravenous line), he or she will not be
allowed to refuse or consent to those measures
for you.
3. Your agent will start making decisions for you
when your doctor determines that you are not
able to make health care decisions for yourself.
4. You may write on this form examples of the
types of treatments that you would not desire
and/or those treatments that you want to
make sure you receive. The instructions may
be used to limit the decision-making power
of the agent. Your agent must follow your
instructions when making decisions for you.
5. You do not need a lawyer to fill out this form.
6. You may choose any adult (18 years of age or
older), including a family member or close
friend, to be your agent. If you select a doctor
as your agent, he or she will have to choose
between acting as your agent or as your
attending doctor because a doctor cannot
do both at the same time. Also, if you are a
patient or resident of a hospital, nursing home
or mental hygiene facility, there are special
restrictions about naming someone who works
for that facility as your agent. Ask staff at the
facility to explain those restrictions.
7. Before appointing someone as your health care
agent, discuss it with him or her to make sure
that he or she is willing to act as your agent.
Tell the person you choose that he or she will
be your health care agent. Discuss your health
care wishes and this form with your agent. Be
sure to give him or her a signed copy. Your
agent cannot be sued for health care decisions
made in good faith.
8. If you have named your spouse as your health
care agent and you later become divorced
or legally separated, your former spouse can
no longer be your agent by law, unless you
state otherwise. If you would like your former
spouse to remain your agent, you may note
this on your current form and date it or
complete a new form naming your former
9. Even though you have signed this form, you
have the right to make health care decisions
for yourself as long as you are able to do so,
and treatment cannot be given to you or
stopped if you object, nor will your agent have
any power to object.
10. You may cancel the authority given to your
agent by telling him or her or your health care
provider orally or in writing.
11. Appointing a health care agent is voluntary.
No one can require you to appoint one.
12. You may express your wishes or instructions
regarding organ and/or tissue donation on
this form.
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