HCP Form
HCP Form
HCP Form
The New York Health Care Proxy Law allows you to appoint someone you trust for example, a family member or close friend to make health care decisions for you if you lose the ability to make decisions yourself. By appointing a health care agent, you can make sure that health care providers follow your wishes. Your agent can also decide how your wishes apply as your medical condition changes. Hospitals, doctors and other health care providers must follow your agents decisions as if they were your own. You may give the person you select as your health care agent as little or as much authority as you want. You may allow your agent to make all health care decisions or only certain ones. You may also give your agent instructions that he or she has to follow. This form can also be used to document your wishes or instructions with regard to organ and/or tissue donation.
(5) Your Identification (please 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. Date ____________________________________ Name of Witness 1 (print) __________________________________ Signature _______________________________ Address _________________________________ Date _______________________________________ Name of Witness 2 (print) _____________________________________ Signature __________________________________ Address ____________________________________
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