The New York Health Care Proxy lets you appoint someone you trust to make health-care decisions for you if you lose the ability to make decisions yourself. This page summarizes how the form works and provides a printable version. You don’t need a lawyer or notary — just two adult witnesses.
Bring your completed form to your next visit so we can add it to your record, and give a signed copy to your appointed health-care agent.
Before you sign — key facts
- This form gives the person you choose authority to make all health-care decisions for you, including life-sustaining treatment, unless you say otherwise.
- Unless your agent reasonably knows your wishes about artificial nutrition and hydration (feeding tube or IV nourishment/water), they cannot refuse or consent to those measures for you. Tell them or write your wishes on the form.
- Your agent only starts making decisions when your doctor determines you can’t make your own.
- You can write specific instructions or limits on the agent’s authority. Your agent must follow them.
- Anyone 18 or older can be your agent. The agent and alternate agent cannot sign as witnesses.
- Discuss your wishes with the person you choose before signing, and give them a signed copy.
- If you appoint your spouse and later divorce or legally separate, your former spouse stops being your agent by law unless your form states otherwise.
- You keep the right to make your own decisions whenever you’re able. You can cancel the proxy at any time, in writing or by telling your agent or provider.
Source: New York State Department of Health Health Care Proxy form (1430).
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Health Care Proxy
State of New York — Department of Health
1. Appointment of agent
I,
hereby appoint:
(name, home address, and telephone number)
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 only when and if I become unable to make my own health care decisions.
2. Alternate agent (optional)
If the person I appoint is unable, unwilling, or unavailable to act as my health care agent, I hereby appoint:
(name, home address, and telephone number)
as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.
3. Duration
Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall remain in effect indefinitely.
(Optional: If you want this proxy to expire, state the date or conditions here.)
This proxy shall expire (specify date or conditions):
4. Instructions or limitations (optional)
I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows or as stated below:
For your agent to make decisions about artificial nutrition and hydration (feeding tube or IV), your agent must reasonably know your wishes. Either tell your agent or include them here.
5. Your identification
Your Name (printed)
Your Signature
Date
Your Address
6. Organ and/or tissue donation (optional)
I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply)
If you do not state your wishes, it will not be taken to mean that you do not wish to make a donation, or to prevent a person otherwise authorized by law from consenting on your behalf.
Your Signature
Date
7. Statement by witnesses
Witnesses must be 18 years of age or older and cannot be the health care agent or alternate.
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 or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence.
Witness 1
Name (printed)
Signature
Date
Address
Witness 2
Name (printed)
Signature
Date
Address