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New York suggested health care form
Download the August 2026 New York Health Care Proxy, the suggested form under Public Health Law § 2981, to appoint an agent for medical decisions if you lose capacity. Get the form in editable Word and true fillable PDF. Add the completed sample PDF if you want a filled-in reference.
A state-specific health care proxy packet, reviewed against the current New York statute and ready for instant secure access.
Follows the substance and signing language of the form suggested by PHL § 2981.
Appoint a trusted adult, state limits or instructions, and optionally name an alternate agent.
Complete the file on your device, then print and sign before two adult witnesses.
This download includes 1 document in editable Word and fillable PDF formats. Use the Word version for editing; the fillable PDF can be completed on screen, then printed and signed.
Review the complete form text below before purchasing. Your licensed Word and fillable PDF download is delivered after checkout.
HEALTH CARE PROXY
(N.Y. Public Health Law § 2981)
I, _________________________________________________________________________________
(name of principal)
hereby appoint
__________________________________________________________________________________
__________________________________________________________________________________
(name, home address and telephone number of agent)
as my health care agent to make any and all health care decisions for me, except to the extent I state otherwise.
This health care proxy shall take effect in the event I become unable to make my own health care decisions.
NOTE: Although not necessary, and neither encouraged nor discouraged, you may wish to state instructions or wishes, and limit your agent's authority. Unless your agent knows your wishes about artificial nutrition and hydration, your agent will not have authority to decide about artificial nutrition and hydration. If you choose to state instructions, wishes, or limits, please do so below:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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 the person I appoint above is unable, unwilling or unavailable to act as my health care agent, I hereby appoint
__________________________________________________________________________________
__________________________________________________________________________________
(name, home address and telephone number of alternate agent)
as my health care agent.
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:
(Please complete the following if you do NOT want this health care proxy to be in effect indefinitely):
This proxy shall expire: _____________________________________________________________
OPTIONAL — ORGAN AND TISSUE DONATION
Publisher-added optional section authorized by N.Y. Public Health Law § 2981(5)(f). Initial one election to state your wishes or limit your agent's authority regarding donation. Failure to state wishes or instructions does not imply a wish not to donate.
I donate any needed organs and tissues.
I donate only the following organs and tissues (list below if you initial this election):
I do not donate any organs or tissues.
I limit my health care agent's authority regarding donation as follows (describe below if you initial this election):
__________________________________________________________________________________
__________________________________________________________________________________
Principal's Signature: _______________________________________________________________
Address: __________________________________________________________________________
Date: _____________________________________________________________________________
WITNESS ATTESTATION
I declare that the person who signed or asked another to sign this document is personally known to me and appears to be of sound mind and acting willingly and free from duress. He or she signed (or asked another to sign for him or her) this document in my presence and that person signed in my presence. I am not the person appointed as agent by this document.
Witness 1 Signature: _______________________________________________________________
Witness 1 Printed Name: ____________________________________________________________
Witness 1 Address: _________________________________________________________________
Witness 2 Signature: _______________________________________________________________
Witness 2 Printed Name: ____________________________________________________________
Witness 2 Address: _________________________________________________________________
Legal currency, verified
This New York Health Care Proxy lets you appoint an adult you trust to make health care decisions if you lose decision-making capacity. It follows the suggested form in New York Public Health Law § 2981 and includes space for instructions and an optional anatomical-gift election.
Public Health Law § 2981 provides a suggested proxy form rather than requiring one exact layout. This document preserves the form’s substance and was reviewed against current New York law in August 2026.
The form names a health care agent and optional alternate, states when authority begins, provides space for limits or treatment instructions, and includes an optional organ-and-tissue-donation section.
You must sign and date the proxy in the presence of two adult witnesses, who also sign and state that you appeared to act willingly and free from duress. The person appointed as agent cannot serve as a witness.
Your purchase includes the complete form in editable Word and true fillable PDF. A completed sample is available as a filling reference.
Use a New York Living Will to record treatment wishes in more detail. For property and finances, see the New York Statutory Short Form Power of Attorney.
This form is not legal advice and does not replace advice from a New York attorney or health care professional about your circumstances.
ILRG is committed to top quality legal forms that are valid in all states. If you are not 100 percent satisfied after purchase, contact us for a full refund.
PHL § 2981 provides it as a suggested form. Another form may be used if it substantially complies with the statute.
Sign and date before two adult witnesses. Your appointed agent cannot be a witness.
Yes. The form includes an optional anatomical-gift section.
No. Use a financial power of attorney, such as New York item 265, for property matters.
Both contain the same form text. Word is editable and the PDF is fillable before printing and signing.