COMBINED Health Care Proxy (Health Care Surrogate), Living Will and Releasd of Information.
Note: 1) THIS IS NOT A POWER TO BE USED BY AN ATTORNEY IN FACT FOR CONDUCTING BUSINESS. 2) New York State permits your family/friends to communicate your specifically stated wishes regarding health care and withdrawal of life support. It also authorizes, but does not require, that you may put your wishes in writing. In order to look and read in a familiar fashion to health care providers in other states, this form is both "acknowledged" and "witnessed" ; a specific release of information is included, and the word "surrogate" is used in addition to the term "proxy" ("proxy" is a New York term) so there can be no confusion that the person(s) designated have all requisite authority.)
I, residing at , , New York being over the age of eighteen (18) and of sound mind, willfully and voluntarily nominate, constitute and appoint as regards this Health Care Proxy(Health Care Surrogate) /Release/ Living Will, the following named persons:
residing at residing at
which appointment also include day to day medical decisions as may be delegated by the laws of the State of New York in a Health Care Proxy. I ask that insofar as is reasonably possible, these people be consulted first, and in order set forth, in respect to these matters and that their decisions/communications control; in the event they are unavailable, unable to act or to continue to act, or disagree decisions my doctor shall take actions consistent with the wishes I have herein set forth. 1. RELEASE OF INFORMATION
The undersigned hereby authorizes and directs that all medical information including without limitation opinions, notes, treatment, records, test results, opinion, prognosis, diagnosis, correspondence, consultants records, and all other medical information be provided and delivered unto the persons named herein. This is a continuing release which does not expire unless communicated in writing by me See Note 1 below. 2. HEALTH CARE PROXY (Surrogate)
a) The persons named herein shall act as my health care agent(s) to make health care decisions for me, except to the extent I state otherwise, b) This health care proxy shall take effect in the event I become unable to make my own health care decisions. c) I direct my agent to make health care decisions in accordance with my wishes and instructions as stated herein or as otherwise known to him or her. I also direct my agent to abide by any limitations on his or her authority as stated herein or as otherwise known to him or her (which include the discretion granted in note 2 below, d) I understand that, unless I revoke it, this proxy will remain in effect indefinitely or until the date or occurrence of the condition I have stated below. This includes all medical decisions, and is not limited to, Artificial Respiration, artificial nutrition and hydration, CPR, antipsychotic medication, electric shock, antibiotics, psychosurgery, dialysis, transplantation, blood transfusions, abortion, and sterilization. Further the scope of my directions are granted hereby - are as follows:
3. FURTHER PARTICULARS OF MY INTENT - LIVING WILL:
A) THE PROVISIONS OF MY LIVING WILL BECOME AFFECTIVE IN THE FOLLOWING CIRCUMSTANCES
1) If at any time I should have an incurable injury, disease or illness resulting in a terminal condition that will cause my death within a relatively short time, or,
2) I am permanently unconscious, or
3) I have brain damage or disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, or
4) in the event of extreme age and/or extreme infirmity or in cases of extreme hardship as recognized by law and/or the Compassionate Practice of Medicine, and where application of artificial life sustaining procedures and/or treatment serve only to prolong a process of dying for which there is no reasonable (not futile, not significantly medically questionable, or not medically contra-indicated) medical alternative(s) except making provision for the relief of pain, and
5) provided footnote 1 is not applicable, then I direct
B) ARTIFICIAL LIFE SUPPORT - In Circumstances 1-5:1) I direct that artificial life support treatment be withheld or withdrawn where not necessary for my comfort or to alleviate pain. I request that all available medication for the relief of pain and my comfort be administered even if I am rendered unconscious and my life is thereby shortened.
2) In the absence of my ability to give instructions regarding the use of artificial life sustaining procedures, it is my intention that this directive shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal. Medical treatments shall be broadly defined and include, but not be limited, to Respiration, anti-psychotic medication, antibiotics, psychosurgery, dialysis, transplantation, blood transfusions.
D) NUTRITION AND HYDRATION - In Circumstances 1-5:
1) I direct that such artificial life sustaining procedures to be withheld or withdrawn under the circumstances set forth above shall include procedures to accomplish the purposes of nutrition and hydration. I recognize that I shall surely die if nutrition hydration is withheld and I request that all available medication for the relief of pain and my comfort be administered even if I am rendered unconscious and my life is thereby shortened.
- In Circumstances 1-5: 1) Although I realize that I may legally have to periodically renew this directive, in the event cardio-pulmonary resuscitation may be necessary to sustain my life or to revive my life, this written instrument entrusts the communication that, I decline same and direct my designee to proceed accordingly.
E) CARDIO-PULMONARY RESUSCITATION
4) GENERAL PROVISIONS
1) I understand the full impact of this Living Will/ Health Care Proxy and have undertaken due medical, philosophical, moral and religious consultation in regards thereto.
2) Nothing pertaining to this document or the exercise of any discretion or powers under it shall in any way effect or invalidate my Will or effect or invalidate the usual order of or right to descent and distribution and I, in all ways and manners, agree to indemnify and hold harmless the persons designated hereunder for the exercise of any discretion in regards to the discharge of the duties contemplated hereby, including such descent and distribution and I direct that person's right to share in my estate shall not be effected by any matter arising hereunder.
3) If any sentence, clause or paragraph of this document shall in substance or intent be declared by a Court of competent jurisdiction to be invalid and not binding, or contrary to public policy, the balance of such sentence, clause or paragraph, and if possible such sentence, clause or paragraph as it may be legally construed, shall together with the balance of this document have full force and effect.
4) The declarations and provisions made herein and powers of my Health Care Proxy shall not be effected by my subsequent disability or incompetence.
5) To induce any third party to act hereunder, I hereby agree that any third party receiving a duly executed copy or facsimile of this instrument may act hereunder, and that revocation or termination hereof shall be ineffective as to such third party unless and until actual notice or knowledge of such revocation or termination shall have been received by such third party, and I for myself and for my heirs, executors, legal representatives and assigns, hereby agree to indemnify and hold harmless any such third party from and against any and all claims that may arise against any such third party by reason of such third party having relied on the provisions of this instrument.
6) If it is feasible, I wish to die at home and not in the hospital and I do not want to be transferred to a hospital unless my condition makes it impractical for me to be treated at home, as may be the case during severe hemorrhage, or extreme restlessness, convulsions or unmanageable pain, unavailability of people to well assist me; in which case, then as soon as possible, I want to be sent back home.
7) I recognize that there may be many instances besides those described above in which the compassionate practice of good medicine dictates that life-sustaining treatment be withheld or withdrawn and I DO NOT INTEND THAT THIS INSTRUMENT BE CONSTRUED AS AN EXCLUSIVE ENUMERATION OF THE CIRCUMSTANCES IN WHICH I HAVE DECIDED TO FOREGO LIFE SUSTAINING TREATMENT. To the contrary, it is my express direction that whenever the compassionate practice of good medicine dictates that life-sustaining treatment should not be administered, such treatment shall be withheld or withdrawn from me. I similarly direct that in the event I am able to personally communicate a decision to forego life-sustaining treatment in other circumstances than those described herein, such instructions shall be followed to the same extent as if originally included in this declaration.
Note 1:
am giving permission to any doctor, hospital, lab, insurer or other health care provider and their employees and representatives to disclose any and all records containing health care information. This authorization includes any information concerning any illness, injury, physical or mental impairment or other condition of mine including conditions, illnesses and injuries, psychiatric or other mental conditions; alcohol, drug or other substance abuse, pychotherapy notes, clinical mental health records maintained by a facility licensed or operated by the Office of Mental Health or the Office of Mental Retardation and Developmental Disabilities, records containing information about HIV and AIDS or other sexually transmissible diseases. The types of records that may be disclosed includes, patient questionnaires, patient intake sheets, referral forms, patient history forms, office notes, reports, charts, x-rays or other films, etc., and copies of hospital and medical records relating to services rendered to me. I waive any rights I may have under Federal and State privacy laws if the persons named herein gives my information to others. This authorization does not release the requestor or the provider from liability for any improper violation of my HEALTH CARE PRIVACY. Photocopies of this authorization shall be accepted as originals
I know that I may revoke this authorization at any time in writing at the address shown on this form. Any revocation will not apply to actions already taken in reliance on this authorization before written notice of revocation is sent. This authorization does not expire.
Note 2:
If I have been diagnosed as pregnant and that diagnosis is known to my physician, any directive that may terminate my life shall not automatically apply until the time of delivery. If I am unconscious or otherwise unable to communicate my wishes and I am pregnant I vest and authorize the people named herein to proceed under the powers and immunities provided herein in communicating my wishes and/or making the decisions for my health care and life after taking into consideration of my health needs and prognosis for a full recovery, the condition of and viability of such fetus and any risks to me if I am capable of a full recovery of carrying the fetus to term, and any other then extent circumstances. They are empowered to make decisions regarding me and the fetus, always considering the likely hood of my making a full recovery, even though the death of one or the other of us may be involved. I do not want a family fight. If I am married to the father of my in vitro child after the date of executing this instrument, if I am then living with my husband as man and wife, and if my then husband is not named herein, my husband’s wishes shall control. After delivery, if I am alive, the remaining provisions of this instrument both Health Care Proxy and Living Will shall be followed no matter the discretion I have otherwise granted in this pregnancy provision. /Release/ Living Will
IN WITNESS WHEREOF, I hereunto sign my name and affix my seal this______th of , 20___.
___________________________________(L.S.)
SUBSCRIPTION OF WITNESSES
We, whose names are hereto subscribed, DO CERTIFY UNDER PENALTIES OF LAW, that on the _________________________TH day of , 20___ , , the maker of this Living Will, the maker above named, an adult we believe to be of sound mind, freely and voluntarily: subscribed his/her name to this instrument in our presence (direct sight) and in the presence of each of us, and at the same time, in our presence and hearing, acknowledged and declared the same to be a Living Will/Resuscitation Directive/Designation of Agent/Health Care Proxy, and requested us and requested each of us, to sign our names thereto as witnesses to the execution thereof which we hereby do in the presence of the maker and of each other on the day of the date of this said Living Will/Resuscitation Directive/Designation of Agent/Health Care Proxy, and we write opposite our names our respective places of residence.
We affirm that each of us is a) eighteen (18) years or more of age, b) are neither married to the maker nor blood relatives of the maker, c) are not the attending physician or employee of the attending physician or of a health facility in which the maker is a patient, d) have no claim against any portion of the maker's estate and e) are not directly financially responsible for the maker's medical care.
___________________________ residing at _______________________________________
__________________________ residing at ________________________________________
ACKNOWLEDGMENT OF SIGNATORY
State of New York)
)ss
County of __________ )
On the day of , 20______ , before me, the undersigned, a Notary Public in and for said state, personally appeared _____________________________________ to me known or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument.
___________________________________
Signature of Notary Public
Prepared by the firm of Cropsey & Cropsey, Albion, New York 14411 Tel. (585-589-9400).
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