New York Medical Power of Attorney
This Medical Power of Attorney is created in accordance with the laws of the State of New York. It allows you to designate someone to make healthcare decisions on your behalf if you are unable to do so.
Principal Information:
- Name: ____________________________
- Address: ____________________________
- City, State, Zip Code: ____________________________
- Date of Birth: ____________________________
Agent Information:
- Name: ____________________________
- Address: ____________________________
- City, State, Zip Code: ____________________________
- Phone Number: ____________________________
Durability of Power: This Medical Power of Attorney shall remain in effect even if I become incapacitated.
Healthcare Decisions: My agent is authorized to make any and all healthcare decisions on my behalf, including but not limited to:
- Choosing healthcare providers.
- Consenting to or refusing medical treatments.
- Accessing my medical records.
- Making decisions about life-sustaining treatments.
Signature:
By signing below, I confirm that I am of sound mind and voluntarily appoint the above-named agent to act on my behalf regarding my medical care.
Principal's Signature: ____________________________
Date: ____________________________
Witnesses: This document must be signed in the presence of two witnesses who are not related to you and who are not your healthcare providers.
Witness 1 Signature: ____________________________
Date: ____________________________
Witness 2 Signature: ____________________________
Date: ____________________________
It is advisable to keep this document in a safe place and to inform your agent and family members of its existence.