PREPARED BY ATTORNEY
D. VICTOR PELLEGRINO ESQ.
(315) 733-0417 WWW.ESTATEANDELDERLAW.COM
EMAIL:
DICK@ESTATEANDELDERLAW.COM
Revised: May 12, 2008
HEALTH CARE PROXY
(1)
I
Address:
Phone:
hereby appoint:
Name
Address
Phone
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 when and if I become unable to make my own health care
decisions.
(2) Optional instructions: I direct my agent to make health care decisions in accord with my wishes and limitations as stated below, or as he or she otherwise knows. (Attach additional pages if necessary.)
__________________SEE ATTACHED LIVING WILL__________________
(Unless your agent knows your wishes about artificial hydration [feeding tubes], your agent will not be allowed to make decisions about artificial nutrition and hydration. See instructions for samples of language you could use.)
(3) I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (AHIPAA@), 42 USC 1320d and 418CFR 160-164. I authorize: any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health-care provider, any insurance company and the Medical Information Bureau Inc. or other health-care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any prior agreement that I may have made with my health-care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health-care provider.
(4) Name of substitute or fill-in agent if the person I appoint above is unable, unwilling or unavailable to act as my health care agent.
Name:
Address:
Phone:
(5) Unless I revoke it, this proxy will remain in effect indefinitely, or until the date or conditions stated below. This proxy shall expire (specific date or conditions, if desired):
(6) Optional: Organ and/or Tissue Donation.
I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply)
Any needed organs and/or tissues
The following organs and/or tissues
Limitations:
(7)
Signature:
_________________________
Name:
Date:
Address:
Statement by Witnesses (must be 18 or older)
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/her own free
will.
He/She signed (or asked another to sign for them) this document in
my presence.
Witness: 1__________________________________________________________
Address:
Witness: 2_________________________________________________________________
Address: ________________________________________________________________
This is an important legal document. Before signing, you should understand the following facts:
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. However, in New York State, only a health care agent you appoint has the legal authority to make treatment decisions if you are unable to decide for yourself. Appointing an agent lets you control your medical treatment by:
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.
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, but if it is not properly filled out and witnessed, it will be totally ineffective and your family may have to petittion a court to have a health care guardian appointed for you which is expensive, time consuming and inconvenient. You don't need 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.
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.
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.
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.
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.
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:
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.
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.
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.
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.
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.
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 know in advance all the 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.
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.
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.
No. The power of a health care agent to make health care decisions on your behalf ends upon your death. Noting your wishes on your Health Care Proxy form allows you to clearly state your wishes about organ and tissue donation
It is important to note your wishes about organ and/or tissue
donation so that family members who will be approached about donation are aware
of your wishes. However, 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 spouse, 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 any other legally
authorized person.
What if I want to give
specific instructions?
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:
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This
a great link to The End Of Life Guide, written by the New York State Attorney
General's Office. It will explain Health Care Proxies, Living Wills and Do
Not Resusitate Orders.
I hope you find the same useful.
http://www.oag.state.ny.us/health/EOLGUIDE012605.pdf
Email: