Health Care Proxy, New York

NEW YORK STATE

HEALTH CARE PROXY FORM

1.      I, __________________________________________________________

hereby appoint

(name)

(address)

(city, state, zip)

(home phone)                         (work phone)

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.  Optional:  Alternate Agent

If the person I appoint is unable, unwilling, or unavailable to act as my health care agent, I hereby appoint

(name)

(address)

(city, state, zip)

(home phone)                         (work phone)

as my health care agent to make any and all health care decisions for me, except to the extent that I say 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):

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