Health Care Proxy

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, eye 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 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 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, eye 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 different 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 different 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.
Frequently Asked Questions, continued
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, eye and/or
tissue donation?
Yes. Use the optional organ, eye and/or 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, eyes
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, eye and/or tissue donor.
Can my health care agent make decisions for me about organ, eye 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, eye 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, eye and/or tissue donation to your health care
agent, or “health care proxy,” family members, and the person responsible for disposition of your
remains. If you have not already made your wishes to become, or not to become, an organ and/
or tissue donor known, New York Law provides a list of individuals who are authorized to consent
to organ, eye and/or tissue donation on your behalf. They are listed as follows, in order of priority:
your health care agent/proxy; 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; an adult grandchild; a grandparent; a guardian appointed for you by a court
prior to your death; or any other person authorized to dispose of your body.
 Health Care Proxy Form Instructions
Item (1) I have discussed with my agent my wishes
Write the name, home address and telephone about____________ and I want my agent
number of the person you are selecting as to make all decisions about these measures.
your agent. Examples of medical treatments about which
Item (2) you may wish to give your agent special
If you want to appoint an alternate agent, instructions are listed below. This is not a
write the name, home address and telephone complete list:
number of the person you are selecting as • artificial respiration
your alternate agent. • artificial nutrition and hydration (nourish-
ment and water provided by feeding tube)
Item (3)
• cardiopulmonary resuscitation (CPR)
Your Health Care Proxy will remain valid
• antipsychotic medication
indefinitely unless you set an expiration date
• electric shock therapy
or condition for its expiration. This section is
• antibiotics
optional and should be filled in only if you want
• surgical procedures
your Health Care Proxy to expire.
• dialysis
Item (4) • transplantation
If you have special instructions for your agent, • blood transfusions
write them here. Also, if you wish to limit your • abortion
agent’s authority in any way, you may say so • sterilization
here or discuss them with your health care
Item (5)
agent. If you do not state any limitations, your
You must date and sign this Health Care
agent will be allowed to make all health care
Proxy form. If you are unable to sign yourself,
decisions that you could have made, including
you may direct someone else to sign in your
the decision to consent to or refuse life-
presence. Be sure to include your address.
sustaining treatment.
Item (6)
If you want to give your agent broad authority,
You may state wishes or instructions about
you may do so right on the form. Simply write: I
organ, eye and /or tissue donation on this
have discussed my wishes with my health care
form. New York law does provide for certain
agent and alternate and they know my wishes
individuals in order of priority to consent to
including those about artificial nutrition and
an organ, eye and/or tissue donation on your
hydration.
behalf: your designated health care agent/
If you wish to make more specific instructions, proxy; your designated agent to control the
you could say: disposition of your remains; your spouse, if you
If I become terminally ill, I do/don’t want to are not legally separated, or your domestic
receive the following types of treatments.... partner; a son or daughter 18 years of age or
older; either of your parents; a brother or sister
If I am in a coma or have little conscious 18 years of age or older; an adult grandchild;
understanding, with no hope of recovery, a grandparent; a guardian appointed by a
then I do/don’t want the following types of court prior to your death; or any other person
treatments:.... authorized to dispose of your body.
If I have brain damage or a brain disease Item (7)
that makes me unable to recognize people Two witnesses 18 years of age or older must
or speak and there is no hope that my sign this Health Care Proxy form. The person
condition will improve, I do/don’t want the who is appointed your agent or alternate agent
following types of treatments:.... cannot sign as a witness.
 Health Care Proxy
(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 effect 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 effect 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, Eye and/or Tissue Donation

I hereby make an anatomical gift, to be effective upon my death, of:
(check any that apply)
■ Any needed organs, eyes and/or tissues
■ The following organs, eyes and/or tissues

■ Limitations
If you do not state your wishes or instructions about organ, eye 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

Department
of Health
1430 8/22