New York Medical Power of Attorney Form | Health Care Proxy

The New York medical power of attorney, also known legally as a ‘health care proxy’ document,  gives the patient the right to an appointed agent should they be suffering from an illness that causes them to become incapacitated. This authority also includes the decisions regarding end-of-life treatment. The power of attorney is created with §§ 2980-2994 in mind. The power of attorney requires two witnesses to sign it. It can be voided at any time the principal wishes.

How to Write

Health Care Proxy

1 & 2) The principal must enter their details and the details of any agents.

  • Principal`s name.
  • Agent`s name.
  • Agents address.
  • Agent`s telephone number.


3) The principal can enter details regarding the date of expiration of the Health Care Proxy.


4) The principal can state any limitations they wish to impose on their agent`s authority regarding their health care.



5) The principal must enter their personal details.

  • Name.
  • Signature.
  • Date.
  • Address.


Organ And/Or Tissue Donattion

The principal can state their intentions regarding anatomical donation.

  • Check box to donate any required tissues and organs.
  • Check box and enter details of any specific anatomical donation.
  • Enter details of any specific limitations the principal has regarding an anatomical donation.
  • Principal`s signature.
  • Date.


Statement Of Witnesses

7) The witnesses details must be entered.

  • Date.
  • Name.
  • Signature.
  • Address.