Health Care Proxy Form

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A health care proxy may be a legally binding document. In some states, this document may be known as either a living will or an advance healthcare directive. The purpose of the form is to name someone who will make medical decisions (including end-of-life activities) on your behalf. Once this form is completed and properly executed, a copy should be provided to your attending physician and to the hospital that would likely treat you. The person named as your healthcare proxy should also have a copy of the executed document.

What is a health care proxy?

A health care proxy is a legal document that gives you the ability to appoint another party to make health care decisions on your behalf in the event that you become incapable of making these decisions on your own. The document will only be used if you are found to be incapable of make logical medical decisions for yourself.

Health Care Proxy vs Living Will

Another document called a living will is a critically important complement to your health care proxy. While a health care proxy names and authorizes another person to make medical decisions on your behalf, a living will addresses your wishes with regard to life-sustaining medical treatment in the event you become terminally ill, permanently unconscious, or in the end-of-life stages of a fatal illness.

Do you need a health care proxy?

It is important to have a health care proxy for a couple of reasons:

The medical team who will be treating you needs to know who to go to in the event that you become incapacitated or cannot speak for you. They need to know who to talk when important decisions need to be made regarding your medical treatment options.

Having a health care proxy will give you a certain amount of peace of mine. This is because, in the event that you cannot speak for yourself, you will have already designated someone who you trust to express your wishes regarding medical treatment, rather simply leaving it up to chance.

Common situations where a health care proxy can help

Imagine you fall into a coma or persistent vegetative state after an accident or illness, your family members may disagree on whether you should be kept alive on life support or be allowed to pass away naturally. By signing a health care proxy beforehand, you can determine who is to make those life and death decisions on your behalf and save your loved ones a lot of stress and acrimony.

What’s more, if you become partially disabled and need assistance in communicating with your healthcare providers, a health care proxy can help there as well. Without a health care proxy or similar document in place, your medical providers, by law, will not be able to discuss or disclose any of your medical information to the person who will be communicating on your behalf.

Components of a health care proxy

Health care proxies are allowed in 49 of the 50 states and in the District of Columbia. The forms used to create a health care proxy may differ from state to state, but you generally don't need to use any pre-made template, as long as you follow certain guidelines.

The usual guidelines for creating a health care proxy are as follows:

  • Your primary agent's name and address
  • Your alternate agent's name and address
  • The duration of the proxy – without a specified duration your proxy will be invalid
  • Any advance directives that widen or restrict the scope of your agent's authority. For example, should you not want certain life-sustaining treatment measures to be taken, you can stipulate that here. Likewise, if you don't want to receive a blood transfusion or be placed on dialysis, that can be stated here. On the other hand, if you want to grant your agent a great deal of freedom, with very few restrictions, this should also be stated here.
  • Your name, the date upon which you are signing the document, and your signature.
  • Your wishes with respect to organ or tissue donations
  • The signatures of two adult witnesses, other than you and your primary agent, who can attest to the fact that you and your agent both appear to be of sound mind and at least 18 years of age.

You are allowed to have an attorney draft the document for you in order to ensure that it sufficiently expresses your needs and desires. Once your health care proxy is completed and signed, you should keep a copy of it with you at all times. In addition, you should provide copies of the document to your agent(s), significant other, close friends, and health care providers.

What is an agent?

The person you authorize to make healthcare decisions on your behalf is called your “agent”, but may also be referred to as your proxy, representative, or health care surrogate. Just about any competent adult can act as your health care agent - your spouse, children, brother, sister, or even a close friend. It is also wise to pick a backup agent, just in case your primary agent is unable to perform their duties.

Legal Considerations

Some state laws require that all adult individuals fill out a health care proxy form. The form will require personal information about the filing party, including name and address. Information about the agent will also be necessary. The filing party must ensure that the person they choose is legally able to be an agent. Both parties should sign this form, and it may also need to be witness and notarized.

Sample Health Care Proxy


Sample Health Care Proxy

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