Fill - H C P Appointing Your Health Care Agent (New York State)

H C P

Appointing Your Health Care Agent

in New York State

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

condition changes. 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.

This form can also be used to document your wishes or

instructions with regard to organ and/or tissue donation.

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 sta 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 spouse.

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.

Frequently Asked Questions

Why should I choose a health care agent?

If you become unable, even temporarily, to make health care decisions, someone else must decide

for you. Health care providers often look to family members for guidance. Family members may

express what they think your wishes are related to a particular treatment. Appointing an agent lets

you control your medical treatment by:

• allowing your agent to make health care decisions on your behalf as you would want

them decided;

• choosing one person to make health care decisions because you think that person would

make the best decisions;

• choosing one person to avoid conﬂict or confusion among family members and/or

signiﬁcant others.

You may also appoint an alternate agent to take over if your ﬁrst choice cannot make decisions

for you.

Who can be a health care agent?

Anyone 18 years of age or older can be a health care agent. The person you are appointing as

your agent or your alternate agent cannot sign as a witness on your Health Care Proxy form.

How do I appoint a health care agent?

All competent adults, 18 years of age or older, can appoint a health care agent by signing a form

called a Health Care Proxy. You don’t need a lawyer or a notary, just two adult witnesses. Your agent

cannot sign as a witness. You can use the form printed here, but you don’t have to use this form.

When would my health care agent begin to make health care decisions for me?

Your health care agent would begin to make health care decisions after your doctor decides that

you are not able to make your own health care decisions. As long as you are able to make health

care decisions for yourself, you will have the right to do so.

What decisions can my health care agent make?

Unless you limit your health care agent’s authority, your agent will be able to make any health care

decision that you could have made if you were able to decide for yourself. Your agent can agree

that you should receive treatment, choose among dierent treatments and decide that treatments

should not be provided, in accordance with your wishes and interests. However, your agent can

only make decisions about artiﬁcial nutrition and hydration (nourishment and water provided by

feeding tube or intravenous line) if he or she knows your wishes from what you have said or what

you have written. The Health Care Proxy form does not give your agent the power to make non-

health care decisions for you, such as ﬁnancial decisions.

Why do I need to appoint a health care agent if I’m young and healthy?

Appointing a health care agent is a good idea even though you are not elderly or terminally ill. A

health care agent can act on your behalf if you become even temporarily unable to make your own

health care decisions (such as might occur if you are under general anesthesia or have become

comatose because of an accident). When you again become able to make your own health care

decisions, your health care agent will no longer be authorized to act.

How will my health care agent make decisions?

Your agent must follow your wishes, as well as your moral and religious beliefs. You may write

instructions on your Health Care Proxy form or simply discuss them with your agent.

Frequently Asked Questions, continued

How will my health care agent know my wishes?

Having an open and frank discussion about your wishes with your health care agent will put him or

her in a better position to serve your interests. If your agent does not know your wishes or beliefs,

your agent is legally required to act in your best interest. Because this is a major responsibility

for the person you appoint as your health care agent, you should have a discussion with the

person about what types of treatments you would or would not want under dierent types of

circumstances, such as:

• whether you would want life support initiated/continued/removed if you are in a

permanent coma;

• whether you would want treatments initiated/continued/removed if you have a terminal illness;

• whether you would want artiﬁcial nutrition and hydration initiated/withheld or continued or

withdrawn and under what types of circumstances.

Can my health care agent overrule my wishes or prior treatment instructions?

No. Your agent is obligated to make decisions based on your wishes. If you clearly expressed

particular wishes, or gave particular treatment instructions, your agent has a duty to follow those

wishes or instructions unless he or she has a good faith basis for believing that your wishes

changed or do not apply to the circumstances.

Who will pay attention to my agent?

All hospitals, nursing homes, doctors and other health care providers are legally required to

provide your health care agent with the same information that would be provided to you and to

honor the decisions by your agent as if they were made by you. If a hospital or nursing home

objects to some treatment options (such as removing certain treatment) they must tell you or your

agent BEFORE or upon admission, if reasonably possible.

What if my health care agent is not available when decisions must be made?

You may appoint an alternate agent to decide for you if your health care agent is unavailable,

unable or unwilling to act when decisions must be made. Otherwise, health care providers will

make health care decisions for you that follow instructions you gave while you were still able to do

so. Any instructions that you write on your Health Care Proxy form will guide health care providers

under these circumstances.

What if I change my mind?

It is easy to cancel your Health Care Proxy, to change the person you have chosen as your health

care agent or to change any instructions or limitations you have included on the form. Simply ﬁll

out a new form. In addition, you may indicate that your Health Care Proxy expires on a speciﬁed

date or if certain events occur. Otherwise, the Health Care Proxy will be valid indeﬁnitely. If you

choose your spouse as your health care agent or as your alternate, and you get divorced or legally

separated, the appointment is automatically cancelled. However, 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 spouse.

Can my health care agent be legally liable for decisions made on my behalf?

No. Your health care agent will not be liable for health care decisions made in good faith on your

behalf. Also, he or she cannot be held liable for costs of your care, just because he or she is

your agent.

Is a Health Care Proxy the same as a living will?

No. A living will is a document that provides speciﬁc instructions about health care decisions. You

may put such instructions on your Health Care Proxy form. The Health Care Proxy allows you to

choose someone you trust to make health care decisions on your behalf. Unlike a living will, a

Health Care Proxy does not require that you decide in advance decisions that may arise. Instead,

your health care agent can interpret your wishes as medical circumstances change and can make

decisions you could not have known would have to be made.

Where should I keep my Health Care Proxy form after it is signed?

Give a copy to your agent, your doctor, your attorney and any other family members or close

friends you want. Keep a copy in your wallet or purse or with other important papers, but not in a

location where no one can access it, like a safe deposit box. Bring a copy if you are admitted to

the hospital, even for minor surgery, or if you undergo outpatient surgery.

May I use the Health Care Proxy form to express my wishes about organ and/or tissue donation?

Yes. Use the optional organ and tissue donation section on the Health Care Proxy form and be

sure to have the section witnessed by two people. You may specify that your organs and/or

tissues be used for transplantation, research or educational purposes. Any limitation(s) associated

with your wishes should be noted in this section of the proxy. Failure to include your wishes and

instructions on your Health Care Proxy form will not be taken to mean that you do not want to

be an organ and/or tissue donor.

Can my health care agent make decisions for me about organ and/or tissue donation?

Yes. As of August 26, 2009, your health care agent is authorized to make decisions after your

death, but only those regarding organ and/or tissue donation. Your health care agent must make

such decisions as noted on your Health Care Proxy form.

Who can consent to a donation if I choose not to state my wishes at this time?

It is important to note your wishes about organ and/or tissue donation to your health care agent,

the person designated as your decedent’s agent, if one has been appointed, and your family

members. New York Law provides a list of individuals who are authorized to consent to organ and/

or tissue donation on your behalf. They are listed in order of priority: your health care agent; your

decedent’s agent; your spouse, if you are not legally separated, or your domestic partner; a son

or daughter 18 years of age or older; either of your parents; a brother or sister 18 years of age or

older; a guardian appointed by a court prior to the donor’s death; or another person authorized to

dispose of the body.

Frequently Asked Questions, continued

H C P F I

Item (1)

Write the name, home address and telephone

number of the person you are selecting as

your agent.

Item (2)

If you want to appoint an alternate agent,

write the name, home address and telephone

number of the person you are selecting as

your alternate agent.

Item (3)

Your Health Care Proxy will remain valid

indeﬁnitely unless you set an expiration date

or condition for its expiration. This section is

optional and should be ﬁlled in only if you want

your Health Care Proxy to expire.

Item (4)

If you have special instructions for your agent,

write them here. Also, if you wish to limit your

agent’s authority in any way, you may say so

here or discuss them with your health care

agent. If you do not state any limitations, your

agent will be allowed to make all health care

decisions that you could have made, including

the decision to consent to or refuse life-

sustaining treatment.

If you want to give your agent broad authority,

you may do so right on the form. Simply write: I

have discussed my wishes with my health care

agent and alternate and they know my wishes

including those about artiﬁcial nutrition and

hydration.

If you wish to make more speciﬁc instructions,

you could say:

If I become terminally ill, I do/don’t want to

receive the following types of treatments....

If I am in a coma or have little conscious

understanding, with no hope of recovery,

then I do/don’t want the following types of

treatments:....

If I have brain damage or a brain disease

that makes me unable to recognize people

or speak and there is no hope that my

condition will improve, I do/don’t want the

following types of treatments:....

I have discussed with my agent my wishes

about____________ and I want my agent

to make all decisions about these measures.

Examples of medical treatments about which

you may wish to give your agent special

instructions are listed below. This is not a

complete list:

• artiﬁcial respiration

• artiﬁcial nutrition and hydration (nourish-

ment and water provided by feeding tube)

• cardiopulmonary resuscitation (CPR)

• antipsychotic medication

• electric shock therapy

• antibiotics

• surgical procedures

• dialysis

• transplantation

• blood transfusions

• abortion

• sterilization

Item (5)

You must date and sign this Health Care

Proxy form. If you are unable to sign yourself,

you may direct someone else to sign in your

presence. Be sure to include your address.

Item (6)

You may state wishes or instructions about

organ and /or tissue donation on this form.

New York law does provide for certain

individuals in order of priority to consent to an

organ and/or tissue donation on your behalf:

your health care agent, your decedent’s agent,

your spouse , if you are not legally separated,

or your domestic partner, a son or daughter 18

years of age or older, either of your parents,

a brother or sister 18 years of age or older,

a guardian appointed by a court prior to the

donor’s death.

Item (7)

Two witnesses 18 years of age or older must

sign this Health Care Proxy form. The person

who is appointed your agent or alternate agent

cannot sign as a witness.

H C P

(1) I,

hereby appoint

(name, home address and telephone number)

as my health care agent to make any and all health care decisions for me, except to the

extent that I state otherwise. This proxy shall take eect only when and if I become unable to

make my own health care decisions.

(2) Optional: Alternate Agent

If the person I appoint is unable, unwilling or unavailable to act as my health care agent,

I hereby appoint

(name, home address and telephone number)

as my health care agent to make any and all health care decisions for me, except to the extent

that I state otherwise.

(3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this

proxy shall remain in eect indeﬁnitely. (Optional: If you want this proxy to expire, state the

date or conditions here.) This proxy shall expire (specify date or conditions):

(4) Optional: I direct my health care agent to make health care decisions according to my wishes

and limitations, as he or she knows or as stated below. (If you want to limit your agent’s

authority to make health care decisions for you or to give speciﬁc instructions, you may state

your wishes or limitations here.) I direct my health care agent to make health care decisions

in accordance with the following limitations and/or instructions (attach additional pages

as necessary):

In order for your agent to make health care decisions for you about artiﬁcial nutrition and

hydration (nourishment and water provided by feeding tube and intravenous line), your agent

must reasonably know your wishes. You can either tell your agent what your wishes are or

include them in this section. See instructions for sample language that you could use if you

choose to include your wishes on this form, including your wishes about artiﬁcial nutrition

and hydration.

(5) Your Identiﬁcation (please print)

Your Name

Your Signature Date

Your Address

(6) Optional: Organ and/or Tissue Donation

I hereby make an anatomical gift, to be eective upon my death, of:

(check any that apply)

■ Any needed organs and/or tissues

■ The following organs and/or tissues

■ Limitations

If you do not state your wishes or instructions about organ and/or tissue donation on this form,

it will not be taken to mean that you do not wish to make a donation or prevent a person, who

is otherwise authorized by law, to consent to a donation on your behalf.

Your Signature Date

(7) Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the

health care agent or alternate.)

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

be of sound mind and 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

Date

Name (print)

Signature

Address

Witness 2

Date

Name (print)

Signature

Address

1430 11/17

Departmen

of Health

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