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New York Health Care Power of Attorney Form

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The New York health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.

New York Health Care Power of Attorney Form
Medical Power of Attorney
Effective Upon Execution
I, [NAME], a resident of [ADDRESS. COUNTY, STATE]; Social Security
Number [NUMBER] designate [NAME], presently residing at [ADDRESS],
telephone number [PHONE NUMBER] as my agent to make any and all
health care decisions for me, except to the extent I state otherwise in this
document. For the purposes of this document, "health care decision" means
consent, refusal of consent, or withdrawal of consent to any care, treatment,
service, or procedure to maintain, diagnose, or treat an individual's physical or
mental condition. This medical power of attorney takes effect if I become
unable to make my own health care decisions and this fact is certified in
writing by my physician.
Limitations: [Describe any desired limitations, for example, concerning life
support, life-prolonging care, treatment, services, and procedures.]
Inspection and Disclosure of Information Relating to My Physical or
Mental Health: Subject to any limitations in this document, my agent has the
power and authority to do all of the following:
1. Request, review, and receive any information, verbal or written,
regarding my physical or mental health, including, but not limited to,
medical and hospital records;
2. Execute on my behalf any releases or other documents that may be
required in order to obtain this information;
3. Consent to the disclosure of this information.
Additional Powers: Where necessary to implement the health care decisions
that my agent is authorized by this document to make, my agent has the
power and authority to execute on my behalf all of the following:
1. Documents titled or purporting to be a "Refusal to Permit Treatment"
and "Leaving Hospital Against Medical Advice";
2. Any necessary waiver or release from liability required by a hospital or
Duration: This power of attorney exists indefinitely from its date of execution,
unless I establish herein a shorter time or revoke the power of attorney.
New York Health Care Power of Attorney Form