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Speaking for you when you cannot speak for yourself
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Step 1: Create Your Health Care Proxy

Instructions: Please read each item carefully. Review all possible choices before making a selection. When you are finished, click on the "Create My Health Care Proxy" button on the bottom of the page. * = required field
 
1. Enter Your Personal Information
Personal information will not be stored or distributed. 
Name: First* Middle  Last*
Address*
City*
State* (this tool was designed for NY residents, but will apply in many other states. Please enter your correct state abbreviation in the box. Click here for more information)
Zip Code*
 
2. Designate your Health Care Agent
  • A health care agent is someone you designate to make medical decisions for you if you become unable to make decisions yourself.
  • Your agent must be over 18 years old (21 in Colorado), and must be willing to assume this role.
  • If you appoint your spouse as your agent, divorce or legal separation will legally terminate this appointment.
  • Your agent cannot be your health care provider, nor any employee or employer of your health care provider.
    [Click here for more help choosing your health care agent]
 
Name: First* Middle  Last*
Address*
City*
State*
Zip Code*
Phone* ( ) -
Alternate Phone ( ) -
3. Designate an alternate Health Care Agent
An alternate health care agent is a person who can serve as your health care agent if the original agent is unable, unwilling or unavailable to act as your health care agent.  Designating an alternate health care agent is optional. 
 
(*Choose one of the following)
YES, I would like to appoint an alternate health care agent
NO, I do not wish to appoint an alternate health care proxy at this time.
4. Generate Instructions for your healthcare agent
You have the option of giving your agent special instructions. You also have the option of limiting your agent's authority. 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 decision to consent to or refuse life-sustaining treatment.
[Click here for help with generating instructions for your healthcare agent]
 
(*Choose one of the following)
YES, I would like to give my agent special instructions and/or limitations.
NO, My health care agent knows my wishes, and I do not need to list them. I give my agent full authority to act on my behalf for health care decisions.
5.  Address artificial nutrition and hydration

Important:  In New York State, in order for your agent to make health care decisions for you about artificial nutrition and hydration (nourishment and water provided by feeding tube and intravenous line), your agent must reasonably know your wishes. You can either tell your agent your wishes or include them on your Health Care Proxy form.
[Click here for help with artificial nutrition and hydration]

 
(*choose one of the following)
My health care agent knows my wishes regarding artificial nutrition and hydration, and I do not need to list them. I give my agent full authority to make decisions regarding artifical nutrition and hydration.
My health care agent knows my wishes regarding artificial nutrition and hydration, however I would also like to give him or her special instructions and/or limitations.
I would like to give my health care agent specific instructions and/or limitations regarding artificial nutrition and hydration.
I have read the above statement and do not wish to comment about artificial nutrition and hydration in my health care proxy.
6.  Choose optional expiration or limitation
Your Health Care Proxy will remain valid indefinitely unless you set an expiration date or condition for its expiration. Setting expiration criteria is optional
 
(*Choose one of the following)
I would like this health care proxy to remain in effect indefinitely, unless I revoke it.
I would like to set an expiration date.
I would like to set circumstances under which this health care proxy will expire.
I would like to set an expiration date and circumstances under which this health care proxy will expire.
 
7.  Consider organ and/or tissue donation
You have the option to state wishes or instructions about organ and/or tissue donation on your health care proxy. A health care agent cannot make a decision about organ and/or tissue donation because the agent’s authority ends upon your death.  If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.
[Click here for help with organ and/or tissue donation]
 
(*Choose one of the following)
YES, Upon my death, I would like to be an organ and/or tissue donor.
NO, I do not wish to donate my organs, tissues or parts.
I do not wish to state my wishes or instructions regarding organ donation on my health care proxy at this time.

 

 
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