7246
Janus Park Drive, Liverpool New York 13088..........Customer Service (315)
458-4600.........
Franciscan Health Support Services
New
York State Health Care Proxy Form
1.
I, ________________________________________________________________,
hereby appoint
_______________________________________________________________________________
(Name, home address and telephone number)
as my Health Care Agent to make any and all health
care decisions for me, except to the extent that I state otherwise.
This proxy shall take effect when and if I become unable to make
my own health decisions.
2.
Optional instructions:
I direct my Agent to make health care decisions in accordance with
my wishes and limitations as stated below, or as he or she otherwise
knows. (Attach additional pages if necessary.)
_______________________________________________________________________________
_______________________________________________________________________________
3.
Unless your agent knows
your wishes about artificial nutrition and hydration (feeding tubes),
your agent will not be allowed to make decisions about artificial
nutrition and hydration. See instructions on the reverse side for
samples of language you could use.
If no, my wishes about artificial nutrition and hydration are:
_______________________________________________________________________________
4.
Name of substitute or fill-in agent if the person I appoint above
is unable, unwilling, or unavailable to act as my health care
agent:
_______________________________________________________________________________
(Name, home address and telephone number)
5.
unless I revoke it, this
Proxy shall remain in effect indefinitely, or until the date or
conditions stated below. This Proxy shall expire (specific date
or conditions, if desired): ________________________
_______________________________________________________________________________
_______________________________________________________________________________
Statement by Witnesses (must be 18 or older)
I declare that the person who signed this document is 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.
