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NOTICE: THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
(a) This document gives your health care providers or your designated Agent the power and guidance to make most health care decisions according to your wishes when you cannot do so. This document may include what kind of treatment you want or do not want and under what circumstances you want these decisions to be made. You may state where you want or do not want to receive any treatment.
(b) This document will remain valid and in effect until and unless you amend or revoke it. Review this document periodically to make sure it continues to reflect your preferences.
The Declarant may revoke this Health Care Proxy by notifying the Agent or a health care provider orally or in writing or by any other act evidencing a specific intent to revoke the Proxy. This Health Care Proxy shall also be revoked upon execution of a subsequent Health Care Proxy.
(c) Your named Agent has the same right as you have to examine your medical records and to consent to their disclosure for purposes related to your health care or insurance unless you limit this right in this document.
(d) If there is anything in this document that you do not understand, you should ask for professional help to have it explained to you.
HEALTH CARE PROXY
. I, , hereby appoint:
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
as my health care Agent to make any and all health care decisions for me, except to the extent I state otherwise.
RESTRICTIONS ON WHO MAY BE A HEALTH CARE AGENT:
- A physician shall not act as the Declarant's attending physician if serving as the Declarant's Agent, unless the physician declines the appointment as Agent. No physician affiliated with a mental hygiene facility or a psychiatric unit of a general hospital where the Declarant resides or is treated may serve as agent unless the physician is related to the Declarant by blood, marriage or adoption.
- An operator, administrator or employee of a hospital may not be appointed as a health care Agent by any person who, at the time of the appointment, is a patient or resident of, or has applied for admission to, such hospital. This restriction shall not apply to the operator, administrator or employee of a hospital if he or she is related to the Declarant by blood, marriage or adoption.
- No person shall serve as the health care Agent for more than ten Declarants unless the Agent is the spouse, child, grandchild, great grandchild, parent, brother, sister or grandparent of the Declarant.
. CREATION OF HEALTH CARE PROXY. This Health Care Proxy shall take effect in the event I become unable to make my own health care decisions.
. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I grant to my Agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, the authority to direct the withdrawal and withholding of artificially administered food and fluids.
In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent. If my desires regarding a particular health care decision are not known to my Agent, then my Agent shall make the decision for me based upon what my Agent believes to be in my best interests.
. DURATION. I understand that, unless I revoke it, this Proxy
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. GENERAL PROVISIONS
1. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
2. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
3. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
(YOU MUST DATE AND SIGN THIS HEALTH CARE PROXY
IN THE PRESENCE OF TWO WITNESSES)
I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration.
Signed on _____ day of _______________, _____.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| , |
| Birthdate: |
I declare that the person who signed or asked another to sign this document is personally known to me and appears to be of sound mind and acting willingly and free from duress. He or she signed (or asked another to sign for him or her) this document in my presence and that person signed in my presence. I am not the person appointed as Agent by this document. I am at least eighteen years old.
| Witness Signature: | ________________________________________ |
Date: _________________________
| Witness Signature: | _________________________________________ |
Date: ________________________
LIMITATIONS ON WHO MAY SERVE AS A WITNESS
1. Each witness must be at least eighteen years old.
2. The person appointed as Agent shall not act as witness to the execution of the Health Care Proxy.
3. If the Declarant resides in a mental hygiene facility operated or licensed by the office of mental health, at least one witness shall be an individual who is not affiliated with the facility, and if the mental hygiene facility is also a hospital as defined in subdivision 10 of section 1.03 of the mental hygiene law, at least one witness shall be a qualified psychiatrist.
4. For persons who reside in a mental hygiene facility operated or licensed by the office for people with developmental disabilities, at least one witness shall be an individual who is not affiliated with the facility and at least one witness shall be a physician or clinical psychologist who satisfies the requirements of the New York statute.
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It's very simple to grant or receive the authority you might need with a free New York Medical Power of Attorney template from Rocket Lawyer:
This method is, in many cases, much less expensive than working with the average law firm. If necessary, you can prepare a Medical PoA on behalf of a family member, and then help that person sign after you've drafted it. Please remember that for a PoA form to be considered legally valid, the principal must be a mentally competent adult when they sign. If the principal has already been declared incompetent, a conservatorship may be required. When managing this situation, it is best for you to talk to a lawyer .
Every person over 18 years old should have a Medical Power of Attorney. Even though it is challenging to acknowledge, a time could come when you aren't able to make your own healthcare decisions. Common occasions in which a PoA may be helpful include:
Regardless of whether this New York Medical Power of Attorney is being created as a result of an emergency or as part of a long-term plan, notarization and/or witnesses can help to protect your agent if someone doubts their privileges and authority.
When discussing the subjects of estate planning and elder care with legal or medical professionals, you might find that "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" are used interchangeably. In actuality, they are one and the same. That being said, you should keep in mind that it is absolutely possible to establish power of attorney over affairs that are not health-related. In that case, "proxy" is not typically used.
New York Medical PoA forms are usually simple to make; however, you or your agent could still have questions. Getting an attorney to double-check your document can take a lot of time if you do it alone. Another approach could be through Rocket Lawyer attorney services. Premium members can request guidance from an experienced attorney or pose additional questions. As always, you can Live Confidently® with Rocket Lawyer by your side.
The cost of working with a traditional legal provider to create a Medical Power of Attorney could total anywhere from $200 to $500, based on your location. Rocket Lawyer offers much more than many other Power of Attorney template providers that you might find elsewhere. As a Rocket Lawyer Premium member, you can get up to a 40% discount when hiring an attorney from our network.
With a membership, you may make edits, download it as a PDF document or Word file, and/or print it. In order to make your Power of Attorney truly legal, you will need to sign it. You should provide a final copy of your signed document to your agent(s), care providers, and other impacted parties.
The specifications and restrictions vary in each state; however, in New York, your Power of Attorney will need to be signed by two witnesses. The witnesses to your document cannot include the person who signed the PoA on your behalf (if applicable). As a basic standard, your witness(es) should be over 18 years old, and no witness should simultaneously be designated as your PoA agent.
See New York Medical/Healthcare Power of Attorney law: PBH, Chapter 45, Article 29-C
