Fill and Sign the New York Living Will and Health Care Proxy New York Form

NEW YORK LIVING WILL I, __________________________________, being of sound mind, make this statement as a directive to be followed if I become permanently unable to participate in decisions regarding my Medical care. These instructions reflect my firm and settled commitment to decline medical treatment under the circumstances indicated below. I direct my attending physician and other medical personnel to withhold or withdraw treatment that serves only to prolong the process of my dying, if I should be in an incurable or irreversible mental or physical condition with no reasonable expectation of recovery. These instructions apply if I am: a) in a terminal condition; b) permanently unconscious; or c) if I am conscious but have irreversible brain damage and will never regain the ability to make decisions and express my wishes. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing treatment. While I understand that I am not legally required to be specific about future treatments, if I am in the condition(s) described above, I feel especially strong about the following forms of treatment. 1. I do not want cardiac resuscitation. 2. I do not want mechanical respiration. 3. I do not want tube feeding. 4. I do not want antibiotics. 5. I do want maximum pain relief. Other instructions (insert personal instructions): _________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. 1 A. General Grant of Power and Authority. Subject to any limitations in this Directive, 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; and (4) Consent to the donation of any of my organs for medical purposes. B. HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider. I HEREBY APPOINT: Name: ____________________________________________________________ Address: __________________________________________________________ Phone Number: ____________________________________________________ as my Health Care Agent to make all health care decisions for me in conformity with the guidelines I have expressed in this document. I direct my Agent to make health care decisions in accordance with my wishes and instructions as stated above 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 above or as otherwise known to him or her. In the event my Health Care Agent is unable, unwilling, or unavailable to serve as such, then I appoint as my substitute health care agent (with the same powers that I have heretofore enumerated). Name: ___________________________________________________________ Address: __________________________________________________________ 2 Phone Number: ____________________________________________________ I understand that unless I revoke it, this living will and health care proxy will remain in effect indefinitely. These directions express my legal right to refuse treatment, under the laws of New York. Unless I have revoked this instrument or otherwise clearly and explicitly indicated that I have changed my mind, it is my unequivocal intent that my instructions as set forth in this document be faithfully carried out. Signature: _________________________________________________________ Address: __________________________________________________________ Date: _____________________________________________________________ Statement By Witnesses (Must Be 18 or Older): I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence. Witness: ________________________________________________________________ (Signature) (Print Name) Address: ________________________________________________________________ Witness: ________________________________________________________________ (Signature) (Print Name) Address: ________________________________________________________________ Note: Keep this signed original with your personal papers at home. Give copies of the signed original to your Doctor, Family, Lawyer and others who might be involved in your health care. 3