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How to fill out a Health Care Proxy form


New York State HCP Form Photo: NYSDOH

There is no question that having a Health Care Proxy is a very important document to have, especially if your an elderly individual. A Health Care Proxy is a form where you appoint an agent to make health care decisions on your behalf if you are unable to do so. Here are a few steps to help:

STEP ONE: After you fill in your name you need to appoint an agent. Your HCP agent should be someone that you have discussed your wishes with and could act in your best interest if and when needed too. This person should be at lease 18 years or older. A spouse, partner, sibling or friend could be your HCP agent.

STEP TWO: It is a good idea to appoint a second HCP agent. If the person who is your primary agent is not available or unwilling to perform their duties as your HCP agent the person that you name second can act on your behalf. The same rules apply for the second agent as they do the first agent. Be sure that the second agent  also knows your wishes and should be the wing man for the primary agent.

STEP THREE: You can decide whether or not your want your HCP to have a time limit. This option is important if you are going to go through a major surgery and there are some high risks involved. Most people skip this part of the HCP but it all depends on your situation and what you want. If you don't fill this part out the HCP is effective indefinitely or until you make a new HCP. At that time the new HCP would take precedent over the older one.

STEP FOUR: The most important part of the HCP is the Optional Instructions part. In this section you will lay out specific instructions of what you want your agent to do. The more specific you are the better. These instructions lay out a blue print for what decisions you want made in regards to your health care. In this sections you can say what you want regarding artificial hydration (IVs that can keep you hydrated if you become dehydrated), nutrition (would be a feeding tube that would provide nourishment if you were unable to eat on your own) or respiration (refers to CPR if you were to stop breathing would you want someone/thing breathing for you). In this section feel free to be as specific as you want. The more specific the better. This will serve as a guide for your agent to follow for any health care decisions that might have to be made.

STEP FIVE: In this section you would decided that upon your death whether or not you want to be an organ donor. Here you will be able to decide exactly what you want to be donated. If you do not wish to be a organ donor you do not have to fill this section out

Once you have signed the document you need to have TWO witnesses that are not your HCP agents. Please make sure that it is dated. If you do not have your signature, two witnesses and the date on your HCP it will not be considered valid and will not be acceptable.

According to an article from the University of Michigan Health System a study that will be published April 1 by the New England Journal of Medicine, more that 25% of elderly patients do not have the capacity to make their own medical decisions at the time of their death. Having a Health Care Proxy established before this time comes proves to be effective.

FOR MORE INFORMATION: New York State Health Care Proxy Form


  • Candace M.-DC HIV/AIDS Examiner 5 years ago

    great article. I love how you write it up step by step for HCP "dummies" like me. :)

  • Alexcia H. Buffalo Senior Care Examiner 5 years ago

    Its a simple form. I just want people to know that its something that can be done in 10 mins or less!!!!!!! And for the record Ithink you are very smart!!!!!!! :)

  • melissa -arts & li graffiti examiner 5 years ago

    stumbled & tweeted ;)

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