 | New York Medical Power of Attorney Form |
The New York medical power of attorney form is a document that allows the Principal to grant powers to someone they would trust to make health care decisions on their behalf in the event the Principal becomes incapacitated, whether it be temporarily or permanently. This document offers some protection to the Principal inasmuch as the Principal will continue to make their own health care decisions until a physician puts into writing, that the Principal is no longer able to communicate or is so incapacitated that they are no longer able to make decisions on their own behalf. Until that time, the Agent may not object to any decisions the Principal makes regarding their own health care
The Principal must read through this entire document prior to completing and signing. This document states clearly that the Principal would complete this document voluntarily and that there is no need for an attorney, however, this document is lengthy. If the Principal is uncertain of any of the language, they may wish to consult with an attorney to better educate themselves with regard to how to properly complete the document and receive clear legal advice.
This document must be witnessed by two unrelated witnesses. The document may be revoked at the Principal’s discretion. Simply place the revocation into writing and deliver or serve it to the Agent(s). The Principal may also, complete a new document with a new Agent, this would immediately revoke this document.
How to Write
Step 1 – Appointing Your Health Care Agent in New York State –
- The Principal must take the time to read and review the first six (6) pages of this document
Step 2 – The Parties – Submit the following:
- The Principal’s full name
- AND
- The Agent’s full name
- Home address
- Telephone number
- Read the remainder of this section
Step 3 – Delegation of an Alternate Agent (optional)
If the originally selected Agent, becomes unable or unwilling to serve the Principal may wish to appoint an Alternate to take their place. Provide the following information:
- The Alternate Agent’s full name
- Home address
- Telephone number
- Read the remainder of this section
Step 4 – Expiration Date (Optional) –
- Should the Principal choose to state an expiration date for this document, they may do so by provision of their selected date of expiration in mm/dd/yyyy format.
Step 5 – Additional Instructions to Agent (Optional) –
- Should the Principal wish to limit and/or restrict authority, provide special instructions or state very specific instructions, they may so by placing this information into the lines provided – Should the explanation be extensive and more room is needed, the continuation may be placed on added sheets and attached to this document – If more sheets are required, be certain to date and sign the added sheets.
- Take the time to speak with the Agent providing thorough explanation, in addition to what is being placed into writing to be certain they understand your wishes, not only pertaining to life sustaining information, but even your wishes for hydration and feeding tubes or IV feeding
Step 6 – Principal’s Information – Must be typed or printed:
- Principal’s full name
- Principal’s Signature
- Enter the date that the Principal provided signature in mm/dd/yyyy format
- Provide the Principal’s address (include zip code)
Step 7 – Organ and Tissue Donations (Optional) –
- Should the Principal have the desire to donate organs or tissues as their death becomes eminent, the Principal must first make clear to their Agent(s) the choices that the Principal has made with this regard
- Place the information into writing to ensure that health care providers are also aware of you choice to donate organs and/or tissues, as there is a very specific process required in order to accomplish provision of your generous gift(s)
- Check one of the following boxes:
- Any needed organs and/or tissues
- OR
- The following organs and/or tissues – If the Principal only wish to donate specific organs or tissues, state the specific organs or tissues that the Principal wishes to donate
- If there are limitations that the Principal would like to state, check the “limitations” box and explain the limitations
- It’s important to review the final paragraph in this section before signing
- Enter the Principal’s signature
- Enter the date of the Principal’s signature in mm/dd/yyyy format
Step 8 – Witnesses – Unrelated or uninterested witnesses who are 18 or older, may witness this document:
- Each Witness must read the witness statement. If in agreement each witness must provide the following:
- Date of the Witnesses Signatures
- Printed Names of Witnesses
- Witnesses signatures
- Witnesses Addresses
