en-USH037036035034033 C036032037 P032031030027en-USAppointing Your Health Care Agenten-US en-USin New York Stateen-USThe New York Health Care Proxy Law allows you to en-USappoint someone you trust 227 for example, a family en-USmember or close friend 226 to make health care decisions en-USfor you if you lose the ability to make decisions yourself. en-USBy appointing a health care agent, you can make sure en-USthat health care providers follow your wishes. Your agent en-UScan also decide how your wishes apply as your medical en-UScondition changes. Hospitals, doctors and other health en-UScare providers must follow your agent222s decisions as if en-USthey were your own. You may give the person you select en-USas your health care agent as little or as much authority en-USas you want. You may allow your agent to make all en-UShealth care decisions or only certain ones. You may also en-USgive your agent instructions that he or she has to follow. en-USThis form can also be used to document your wishes or en-USinstructions with regard to organ and/or tissue donation. American LegalNet, Inc. www.FormsWorkFlow.com en-USAbout the Health Care Proxy Form en-USThis is an important legal document. Before signing, you should understand the following facts: 1. þ This form gives the person you choose as your agent the authority to make all health care en-USdecisions for you, including the decision to remove or provide life-sustaining treatment, unless en-USyou say otherwise in this form. 223Health care224 means any treatment, service or procedure to en-USdiagnose or treat your physical or mental condition. 2. þ Unless your agent reasonably knows your wishes about arti026cial nutrition and hydration en-US(nourishment and water provided by a feeding tube or intravenous line), he or she will not be en-USallowed to refuse or consent to those measures for you. 3. þ Your agent will start making decisions for you when your doctor determines that you are not en-USable to make health care decisions for yourself. 4. þ You may write on this form examples of the types of treatments that you would not desire and/ en-USor those treatments that you want to make sure you receive. The instructions may be used to en-USlimit the decision-making power of the agent. Your agent must follow your instructions when en-USmaking decisions for you. 5. þ You do not need a lawyer to 026ll out this form. 6. þ You may choose any adult (18 years of age or older), including a family member or close friend, en-USto be your agent. If you select a doctor as your agent, he or she will have to choose between en-USacting as your agent or as your attending doctor because a doctor cannot do both at the same en-UStime. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, en-USthere are special restrictions about naming someone who works for that facility as your agent. en-USAsk sta025 at the facility to explain those restrictions. 7. þ Before appointing someone as your health care agent, discuss it with him or her to make sure en-USthat he or she is willing to act as your agent. Tell the person you choose that he or she will be en-USyour health care agent. Discuss your health care wishes and this form with your agent. Be sure en-USto give him or her a signed copy. Your agent cannot be sued for health care decisions made in en-USgood faith. 8. þ If you have named your spouse as your health care agent and you later become divorced or en-USlegally separated, your former spouse can no longer be your agent by law, unless you state en-USotherwise. If you would like your former spouse to remain your agent, you may note this on en-USyour current form and date it or complete a new form naming your former spouse. 9. þ Even though you have signed this form, you have the right to make health care decisions for en-USyourself as long as you are able to do so, and treatment cannot be given to you or stopped if en-USyou object, nor will your agent have any power to object. 10. þ You may cancel the authority given to your agent by telling him or her or your health care en-USprovider orally or in writing. 11. þ Appointing a health care agent is voluntary. No one can require you to appoint one. 12. þ You may express your wishes or instructions regarding organ and/or tissue donation on en-US en-USthis form. American LegalNet, Inc. www.FormsWorkFlow.com en-USFrequently Asked Questionsen-USWhy should I choose a health care agent?en-US en-USIf you become unable, even temporarily, to make health care decisions, someone else must decide en-USfor you. Health care providers often look to family members for guidance. Family members may en-USexpress what they think your wishes are related to a particular treatment. Appointing an agent lets en-USyou control your medical treatment by: 225 þ allowing your agent to make health care decisions on your behalf as you would want en-US en-USthem decided; 225 þ choosing one person to make health care decisions because you think that person would en-USmake the best decisions; 225 þ choosing one person to avoid con024ict or confusion among family members and/or en-USsigni026cant others.en-USYou may also appoint an alternate agent to take over if your 026rst choice cannot make decisions en-US en-USfor you.en-USWho can be a health care agent?en-US en-USAnyone 18 years of age or older can be a health care agent. The person you are appointing as en-USyour agent or your alternate agent cannot sign as a witness on your Health Care Proxy form.en-USHow do I appoint a health care agent? en-US en-USAll competent adults, 18 years of age or older, can appoint a health care agent by signing a form en-UScalled a Health Care Proxy. You don222t need a lawyer or a notary, just two adult witnesses. Your agent en-UScannot sign as a witness. You can use the form printed here, but you don222t have to use this form.en-USWhen would my health care agent begin to make health care decisions for me?en-US en-USYour health care agent would begin to make health care decisions after your doctor decides that en-USyou are not able to make your own health care decisions. As long as you are able to make health en-UScare decisions for yourself, you will have the right to do so.en-USWhat decisions can my health care agent make?en-US en-USUnless you limit your health care agent222s authority, your agent will be able to make any health care en-USdecision that you could have made if you were able to decide for yourself. Your agent can agree en-USthat you should receive treatment, choose among di025erent treatments and decide that treatments en-USshould not be provided, in accordance with your wishes and interests. However, your agent can en-USonly make decisions about arti026cial nutrition and hydration (nourishment and water provided by en-USfeeding tube or intravenous line) if he or she knows your wishes from what you have said or what en-USyou have written. The Health Care Proxy form does not give your agent the power to make non-en-UShealth care decisions for you, such as 026nancial decisions.en-USWhy do I need to appoint a health care agent if I222m young and healthy?en-US en-USAppointing a health care agent is a good idea even though you are not elderly or terminally ill. A en-UShealth care agent can act on your behalf if you become even temporarily unable to make your own en-UShealth care decisions (such as might occur if you are under general anesthesia or have become en-UScomatose because of an accident). When you again become able to make your own health care en-USdecisions, your health care agent will no longer be authorized to act.en-USHow will my health care agent make decisions?en-US en-USYour agent must follow your wishes, as well as your moral and religious beliefs. You may write en-USinstructions on your Health Care Proxy form or simply discuss them with your agent. American LegalNet, Inc. www.FormsWorkFlow.com en-USFrequently Asked Questions, en-UScontinueden-USHow will my health care agent know my wishes?en-US en-USHaving an open and frank discussion about your wishes with your health care agent will put him or en-USher in a better position to serve your interests.