If you
lose the ability
to make your
own health care decisions...
...who will
decide for you?


Assemblymember
Joseph R.
Lentol

Dear Neighbor,

Who can make important decisions for you if a serious illness or accident leaves you unable to communicate?

Many people donít realize the state Health Care Proxy Law lets you designate a health care agent to make such decisions.

This brochure answers many questions about the proxy law. Appointing a health care agent is a serious decision. Make sure you talk about it with your family, close friends and your doctor.

Sincerely,

Joseph R. Lentol
Member of Assembly




**Click Here for a Printable Health Care Proxy Form**

Health Care Proxy Form
l) I,
hereby appoint


(name, home address and phone 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 when and if I become unable to make my own health care decisions.

2) Optional: Alternate Agent. 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) 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) 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. (If you want to limit your agentís authority to make health care decisions for you or to give specific instructions, you may state your wishes or limitations here.) I direct my health care agent to make health care decisions in accordance with the following limitations and/or instructions (attach additional pages as necessary).






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 what your wishes are or include them in this section.


5) Your Identification: (print) Your Name


Your Signature
Date

Your Address



6) Optional: Organ and/or Tissue Donation

I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply)

Any needed organs and/or tissues

The following organs and/or tissues

Limitations

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.


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 (print)

Address

Date

Witness 2 (print)

Address

Date



Contact Assemblymember Joseph R. Lentol at:

619 Lorimer Street, 1st Floor Storefront
Brooklyn, New York 11211
(718) 383-7474

Room 632 LOB
Albany, New York 12248
(518) 455-4477

lentolj@assembly.state.ny.us


Back