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New York Health Medical Power of Attorney Form

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New York Health Medical Power of Attorney Form

Updated August 09, 2023

A New York medical power of attorney, or ‘health care proxy,’ is a document that grants an individual the right to represent another person’s medical-related interests. Such a delegation of power can be made pursuant to Article 29-C of the Public Health Law. To be more specific, this statute allows the appointment of a health care agent who will be tasked with making health decisions on the individual’s behalf if that person does not have the capacity to make the decisions themselves.


Health care proxy” means a document delegating the authority to make health care decisions, executed in accordance with the requirements of this article.


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1 – Acquire The New York Health Directive Through This Page

This page supplies the documentation required to detail a Principal’s Health Preferences and Directives with Medical Care through the buttons under the image.

2 – A Formal Appointment Of The Health Care Agent Must Be Provided

The first blank line on the second page will require the Principal’s Full Name.

Record the Health Care Agent’s Legal Name, Complete Address, and Telephone Number on the blank line labeled “Name, Home Address, And Telephone Number after the words “Hereby Appoint”

3 – Address The Options Provided Through This Directive

A few options are available through this document. The first will be that of the Alternate Agent. This entity will automatically be granted the Principal Power to represent the Principal if the Agent declared above cannot or will not. This is the only method by which an Alternate Agent will be granted Principal Power. If the Principal has determined a specific entity for this purpose, then record the Name, Address, and Telephone Number of the Alternate Agent on the blank lines in “(2) Optional: Alternate Agent.”

The next option allows the Principal to define how or when the Principal Authority to make decisions and take actions regarding the Principal’s Health will Terminate. As a default, the document will set the Powers defined here in action at the time of signing for an indefinite period of time (though a Principal can issue a written revocation at any time). If the Principal has a specific event (i.e. inheriting a large sum of money while in a coma) or a specific Termination Date in mind, this should be documented in the area provided in “(3) Unless I Revoke It Or State An Expiration Date Or Circumstances Under Which It Will Expire…”

4 – It Is Recommended To Document The Principal’s Determined Directive

Normally, the Health Care Agent named by the Principal will have direct knowledge of a Principal’s Preferences in a variety of scenarios ranging from health maintenance to treatment to traumatic medical events. However, it is usually considered a good idea to physically document such preferences in this declaration, so they exist in a hard copy that may be referenced if necessary. Item (4) will provide the area required to take this option. Topics the Principal may cover may include (and is not limited to) the Principal’s stance on artificial nutrition, medical intervention for a traumatic life-threatening event, which medical facilities the Agent may or may not admit the Principal to, being rendered in a permanent vegetative state (coma), and life-prolonging procedures. This requires a very frank and all-inclusive discussion with the Principal. Furthermore, the Principal should absolutely read this document after his or her wishes are recorded in this area. If more room is required, you may add additional lines if you are filling out this form using the proper software or, if filling it out manually, you may type up a document continuing this section. Make sure it is labeled, dated, initialed by the Principal, and attached to this Directive before it is signed by the Principal. Note: Only attachments present at the time of signing will be considered a part of this Directive.

5 – The Principal Must Provide A Self Report And Executing Signature

The fifth item, “(5) Your Identification,” must be directly attended to by the Principal issuing his or her Health Care Directive. Four items will need to be provided here by the Principal

The Principal must print his or her Name on the blank space labeled “Your Name”

Below his or her Printed Name, the Principal must sign the blank line designated “Your Signature”

Next, to his or her Signature must record the Date he or she has signed these papers. This Date of Signature should be recorded on the blank line after the word “Date.”

Finally, on the “Your Address” line, the Principal must report his or her Home Address precisely as it appears on his or her Identification (i.e. Driver’s License, Insurance Cards, etc.).

6 – Some Additional Tasks Require Attention

By default, the designated Health Care Agent, or an entity with the legal Authority to, will decide whether anatomical gifts can be obtained from your remains. Locate “(6) Optional: Organ And/Or Tissue Donation.” Three check boxes have been provided to define the Principal’s Preferences in this matter.

If the Principal is willing to donate any needed Organs and/or Tissues upon death, then he or she should mark the first box.

If only specific Organs and/or Tissues will be approved by the Principal as anatomical gifts, they should be listed on the blank lines in the second choice. If this has been done, the Principal must mark the second box.

If there are any Limitations the Principal wishes to apply to Anatomical Gifts or the Principal does not wish to make any, then he or she should mark the third check box and document such limitations on the blank lines provided.

7 – Provide Authentication For The Principal Signature

Two Witnesses must physically watch the Principal sign these papers. In “(7) Statement Of Witnesses” a Witness declaration statement has been provided. Each Witness should read the statement, then upon agreement, supply the Date of his or her Signature as well as his or her Printed Name, Signature, and Address. Two columns have been provided with the appropriately labeled lines (Date, Name Of Witness, Signature, and Address).