The Following information will be needed to complete a Health Care Proxy:
1) The Name and Address of the individaul for whom the Health Care Proxy is for
2) The Name and Address of the individaul you wish to grant your Health Care Proxy to
3) The Name and Addres of an alternate individual you wish to grant your Health Care Proxy to in the event the primary Health Care individual is not available
EXAMPLE
I, _________________, residing at _____________________, NY _____, do hereby appoint _____________, as my Health Care Agent to make any and all health related decisions for me, except to the extent I set forth otherwise in this document.
In the event the person I appoint is unable, unwilling or unavailable to act as my Health Care Agent, I do hereby appoint ____________________, as my alternate Health Care Agent.
Any alternate Health Care Agent serving hereunder shall be vested with all of the rights, powers, authorities, duties, privileges, immunities and discretions which are granted to my Health Care Agent originally appointed herein.
I grant to my Health Care Agent full authority to make any and all health care related decisions for me including, but not limited to, providing informed consent on my behalf. In exercising this authority, my Health Care Agent shall act in accordance with my wishes as set forth in his document or as otherwise known to my Health Care Agent. In the event my wishes are not clear, or a situation arises which is not addressed in the document, my Health Care Agent determines to be in my best interests, based on what is known of my wishes. My Health Care Agent’s authority to interpret my wishes is intended to be as broad as possible, except for any limitations I set forth below. Accordingly, unless specifically limited below, my Health Care Agent is authorized to make any and all health care and health related decisions for me, including without limitation, the following:
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