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Filling Out the NYS Health Care Proxy Form |
Before you begin: print out the NYS Health Care Proxy form. (click to download form)
Item 1: Write your name and the name, home address and telephone number of the person you are selecting as your agent.
Item 2: If you want to name an alternate agent, write the name, home address and telephone number of the person you are selecting as your alternate agent.
Item 3: Your agent's authority will start when you lose capacity and continue until you are once again able to make decisions for yourself, or until you die, unless you write an expiration date or a reason that would change your agent.
Item 4: If you have special instructions for your agent, you should write them here.
Item 5: You must date and sign the 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 your wishes or instructions about organ or tissue donation on this form.
Item 7: Two witnesses at least 18 years of age must sign your proxy form. The person who is appointed agent, or alternate agent, cannot sign as a witness.
If you want to provide specific instructions, complete a Living Will and/or Do Not Resuscitate Form (click to download forms).
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Important Information |
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Forms and information:
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What to do with your health care proxy form
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Advance Directives
