Article Guide
The New York Medical Power of Attorney form is a crucial document that allows individuals to designate a trusted person to make healthcare decisions on their behalf in case they become unable to communicate their wishes. This form is vital for ensuring that your medical preferences are honored, particularly during emergencies or serious health issues. It covers various aspects, including the authority granted to the appointed agent, the types of medical decisions they can make, and any specific instructions regarding treatment preferences. By using this form, you can outline your wishes concerning life-sustaining treatment, pain management, and other critical healthcare choices. It’s important to understand that this document goes into effect only when you are incapacitated, providing peace of mind that your healthcare decisions will be handled according to your values and desires. In New York, completing this form requires careful consideration and must be signed in the presence of a notary or witnesses to ensure its validity.
Preview - New York Medical Power of Attorney Form
New York Medical Power of Attorney
This Medical Power of Attorney serves as a legal document in the State of New York, allowing individuals to appoint someone they trust to make healthcare decisions on their behalf in the event that they are unable to do so. In accordance with New York State laws, this document is designed to respect the rights and wishes of the principal (the person making the document) in regards to their medical treatment and care.
Principal's Information:
- Name: ____________________________________
- Address: __________________________________
- City, State, ZIP: ___________________________
- Date of Birth: _____________________________
- Social Security Number: ____________________
Agent's Information:
- Name: ____________________________________
- Address: __________________________________
- City, State, ZIP: ___________________________
- Phone Number: ____________________________
- Email: ___________________________________
In the event that my above-named agent is unable or unwilling to serve, I designate the following person as my successor agent:
- Name: ____________________________________
- Address: __________________________________
- City, State, ZIP: ___________________________
- Phone Number: ____________________________
- Email: ___________________________________
Authority of Agent:
My health care agent is authorized to make all decisions for me concerning my personal care, medical treatment, hospitalization, and health care and to require, withhold, or withdraw any type of medical treatment or procedure, even if my death ensues.
Special Instructions:
In the space below, I may give special instructions limiting or extending the powers granted to my agent.
______________________________________________________________________________
______________________________________________________________________________
Designation Effective Date:
This document becomes effective immediately upon my incapacity to make my own health care decisions, as determined by medical personnel.
Signature and Acknowledgment:
I, the principal, affirm this Medical Power of Attorney is true and correct to the best of my knowledge. I sign this document voluntarily and with the understanding of its significance.
Principal's Signature: _______________________________ Date: _______________
State of New York
County of ___________________________
On this day, personally appeared before me, _________________________, to me known to be the individual(s) described in and who executed the foregoing instrument, and acknowledged that (he/she/they) executed the same as (his/her/their) free act and deed.
Notary Public Signature: _____________________________ Date: _______________
Notary Public Name (Printed): _______________________
My Commission Expires: _____________________________
PDF Specifications
| Fact Name | Description |
|---|---|
| Definition | The New York Medical Power of Attorney allows an individual to designate someone to make healthcare decisions on their behalf if they become unable to do so. |
| Governing Law | This form is governed by New York State Consolidated Laws, Public Health Law § 2981. |
| Principal | The person creating the document is known as the principal. |
| Agent | The designated individual who will make decisions is referred to as the agent or healthcare proxy. |
| Capacity Requirement | The principal must be of sound mind when signing the document to ensure it is valid. |
| Witness Requirement | The form must be signed in the presence of two witnesses, who cannot be the agent or related to the principal. |
| Revocation | The principal can revoke the power of attorney at any time, as long as they are competent. |
| Durability | This power of attorney remains effective even if the principal becomes incapacitated. |
| Alternative Documents | In addition to the Medical Power of Attorney, individuals may also consider a Living Will for end-of-life decisions. |
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