Advanced directives in health care provide an opportunity to plan for the possibility that, sometime in the future, an individual may lack the decision-making capacity to make known his or her wishes about medical treatment. On January 18, 1991, the Health Care Proxy Law went into effect in New York State. This law enables competent adults to protect their treatment wishes by appointing someone they trust – a health care agent – to decide about medical treatment on their behalf when they are no longer able to decide for themselves.
Additional information about this law and a sample health care proxy form, which can be used or copied, can be found at the end of this Booklet.
VITAL INFORMATION
Vital information should be collected and kept in a safe and convenient place. This should include your social security number, the name and phone number of your primary physician and whom to contact in an emergency. A wallet-size card is a useful way for individuals to keep vital information handy in an emergency. A sample card is provided below.
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Name: |
Health Care Plan |
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Address: |
Medicare Number: |
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Date of Birth: |
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Social Security Number: |
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Phone: |
Medications: |
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Emergency Name: |
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Emergency Number: |
Medical Condition: |
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Physician Number: |
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Click here to
download the Health Care Proxy
About the Health Care Proxy |
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This is an important legal form Before signing this form, you should understand the following facts:
You may write on this form any information about treatment that you do not desire and/or those treatments that you want to make sure you receive. Your agent must follow your instructions (oral and written) when making decisions for you. If you want to give your agent written instructions, do so right on the form. For example, you could say:
Examples of medical treatments about which you may wish to give your agent special instructions are listed below. This is not a complete list of the treatments about which you may leave instructions.
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Talk about choosing an agent with your family and/or close friends. You should discuss this form with a doctor or another health care professional, such as a nurse or social worker, before you sign it to make sure that you understand the types of decisions that may be made for you. You may also wish to give your doctor a signed copy. You do not need a lawyer to fill out this form. You can choose any adult (over 18), including a family member, or close friend, to be your agent If you select a doctor as your agent, he or she may have to choose between acting as your agent, he or she may have to choose between acting as your agent or as your attending doctor, a physician cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. You should ask staff at the facility to explain those restrictions. You should tell the person you choose that he or she will be your health care agent. You should discuss your health care wishes and this form with your agent. Be sure to give him or her a signed copy. Your agent cannot be sued for health care decisions made in good faith. Even after you have signed this form, you have the right to make health care decisions for y~1f as long as you are able to do so, and treatment cannot be given to you or stopped if you object. You can cancel the control given to your agent by telling him or her or your health care provider orally or in writing. Filling Out the Proxy Form Item (I) Write your name and the name, home address and telephone number of the person you are selecting as your agent. Item (2) If you have special instructions for your agent, you should write them here. Also, if you wish to limit your agent's authority in any way, you should say so here. If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decisions to consent to or refuse life-sustaining treatment. Item(3) You may write the name, home address and telephone number of an alternate agent. Item(4) This form will remain valid indefinitely unless you set an expiration date or condition for its expiration. This section is optional and should be filled in only if you want the health care proxy to expire. Item (5) You must date and sign the proxy. If you are unable to sign yourself, you may direct someone else to sign in your presence. Be sure to include your address. Two witnesses at least 18 years of age must sign your proxy. The person who is appointed agent or alternate agent cannot sign as a witness. New York State Department of Health |
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