Keywords: Health Care Proxy; Living Will; Elder Law; Estates and Trusts; Estate Planning; Medical Power of Attorney; Appointment of a Health Care Surrogate; or Attorney-in-Fact.

New York State, along with most other states, permits you to appoint a person to make health care decisions for you in the event you can not make such decisions for yourself. The document is known by several names: health care proxy; medical power of attorney; appointment of a health care surrogate. The person you appoint is variously known as your proxy, health care surrogate; or Attorney-in-Fact.

In addition, you can provide written directions to your health care provider (doctors, nurses, paramedics etc,) or proxy in the event that you are unable to express your own wishes. This document is variously known as a living will, health care declaration or medical directive..

The following text is a simple health care proxy. It is based upon the form stated in New York's Public Health Law. You can use for your own purposes.

A future article will discuss and provide a simple living will. Both forms will be available on this site in *.TXT and PDF format. Other future articles will deal with issues such as end of life planning, discussion with family and friends, selection of an agent, and additional resources available to you.

I, ____________________________________________, residing at _____________________, ___________________________, ________ _________ hereby appoint:

___________________________________________ residing at _________________________,

___________________________, ________ _________ 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.

My agent knows my wishes about artificial nutrition and hydration, ( If you choose to state additional instructions, wishes, or limits, please do so below)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

I direct my agent to make health care decisions in accordance with my wishes and instructions as stated above or as otherwise known to him/her. I also direct my agent to abide by any limitations on his/ her authority as stated above or as otherwise known to him/her.

In the event the person I appoint above is unable, unwilling or unavailable to act as my health care agent, I hereby appoint

_____________________________________________________________________________ (name, home address and telephone number of alternate agent) as my health care agent.

I understand that, unless I revoke it, this proxy will remain in effect indefinitely or until the date or occurrence of the condition I have stated below:

(Please complete the following if you do NOT want this health care proxy to be in effect indefinitely): This proxy shall expire: (Specify date or condition) _____________________________________

_____________________________________________________________________________

Sign and Date: _____________________________________ ________________, 199___

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.

_____________________________________________________________________________ Signature of 1st Witness

Address:______________________________________________________________________

_____________________________________________________________________________ Signature of 2nd Witness

Address:______________________________________________________________________