**NEW YORK HEALTHCARE POWER OF ATTORNEY
(Health Care Proxy, Living Will & HIPAA Authorization)**
[// GUIDANCE: This integrated template satisfies New York’s Health Care Proxy Law (N.Y. Pub. Health Law §§ 2980–2994), incorporates optional living-will/end-of-life directives, and grants the Agent HIPAA-compliant access to medical information (45 C.F.R. pts. 160, 164). Bracketed items must be customized. Remove any bracketed text—INCLUDING GUIDANCE—before finalization.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block (Signature, Witnesses, Notary)
1. DOCUMENT HEADER
1.1 Title & Parties
This Healthcare Power of Attorney (the “Agreement”) is made as of [EFFECTIVE DATE] by and between:
a. [PRINCIPAL NAME], residing at [PRINCIPAL ADDRESS] (“Principal”); and
b. [AGENT NAME], residing at [AGENT ADDRESS] (“Agent”).
1.2 Recitals
WHEREAS, Principal desires to appoint an Agent to make health-care decisions on Principal’s behalf in the event Principal is unable to make or communicate such decisions; and
WHEREAS, Principal wishes to provide legally-binding instructions concerning end-of-life care and authorize Agent to obtain protected health information;
NOW, THEREFORE, in consideration of the mutual promises herein, the parties agree as follows.
1.3 Governing Law
This Agreement shall be governed by and construed under the laws governing health-care decision-making in the State of New York (“Governing Law”).
2. DEFINITIONS
The following capitalized terms shall have the meanings set forth below:
“Advance Directive” – Any written instruction recognized under Governing Law relating to the provision, withholding, or withdrawal of health care when the Principal is incapacitated.
“Alternate Agent” – The individual(s) named in Section 3.2 to act if the Agent is unwilling, unable, or ineligible to serve.
“Health Care Decision” – Any decision to consent to, refuse, withdraw, or discontinue health care, treatment, service, or diagnostic procedure.
“HIPAA” – The Health Insurance Portability and Accountability Act of 1996, as amended, and its implementing regulations at 45 C.F.R. Parts 160 & 164.
“Incapacitated” – As defined in N.Y. Pub. Health Law § 2983(1): unable to appreciate the nature and consequences of health-care decisions and unable to reach and communicate a decision.
“Good Faith” – Honest intention to act without taking unfair advantage and with reasonable belief that the action is lawful and in Principal’s best interest.
3. OPERATIVE PROVISIONS
3.1 Appointment of Agent
Principal hereby appoints Agent, acting in Good Faith, to make any and all Health Care Decisions for Principal that Principal could make personally if not Incapacitated.
3.2 Appointment of Alternate Agent(s)
If Agent is unavailable, the following, in the order listed, shall serve:
1. [ALTERNATE AGENT #1 NAME & ADDRESS]
2. [ALTERNATE AGENT #2 NAME & ADDRESS]
3.3 Scope of Authority
Agent is authorized to:
a. Consent to, refuse, or withdraw any treatment, service, or procedure;
b. Make decisions regarding life-sustaining treatment consistent with Section 3.4;
c. Authorize admission to or discharge from any healthcare facility;
d. Employ and discharge healthcare personnel;
e. Access and disclose medical records as permitted under Section 3.5;
f. Execute documents required to implement these decisions.
3.4 End-of-Life & Special Instructions
[// GUIDANCE: Customize or delete any of the following bracketed directives.]
a. Life-Sustaining Measures: Principal [WISHES / DOES NOT WISH] to receive artificial respiration, cardiopulmonary resuscitation (CPR), or mechanical ventilation if terminally ill or persistently unconscious.
b. Artificial Nutrition & Hydration: Principal [WISHES / DOES NOT WISH] to receive tube feeding.
c. Palliative Care: Principal directs that comfort care [SHALL / SHALL NOT] be prioritized over prolongation of life.
d. Organ Donation: Principal [DOES / DOES NOT] wish to donate organs or tissues; limitations [IF ANY].
3.5 HIPAA Authorization
Pursuant to HIPAA, Principal expressly authorizes any covered entity to disclose to Agent all protected health information (“PHI”) of Principal, whether oral or recorded, in order to facilitate Agent’s duties. This authorization is effective immediately and survives Principal’s death to the extent necessary to carry out post-mortem decisions contemplated herein.
3.6 Duration & Revocation
a. This Agreement remains effective until revoked by Principal, superseded by a subsequent valid directive, or terminated per Governing Law.
b. Principal may revoke at any time by (i) written notice, (ii) oral statement in the presence of two adults, or (iii) execution of a later-dated proxy.
c. Divorce or legal separation from Agent automatically revokes Agent’s authority, unless Section 9.4 states otherwise.
4. REPRESENTATIONS & WARRANTIES
4.1 Principal
a. Capacity: Principal represents that Principal is of sound mind and at least 18 years of age.
b. Voluntariness: Execution is voluntary and not the result of duress, fraud, or undue influence.
4.2 Agent
a. Eligibility: Agent is at least 18 years of age and not disqualified under Governing Law.
b. Acceptance: By signing below, Agent accepts the appointment and warrants to act in Good Faith and in accordance with Principal’s known wishes or, if unknown, Principal’s best interest.
5. COVENANTS & RESTRICTIONS
5.1 Agent’s Affirmative Covenants
Agent shall:
1. Consult available medical personnel and reasonably attempt to discern Principal’s wishes.
2. Keep reasonably contemporaneous records of major Health Care Decisions made.
3. Provide information to family members as appropriate and consistent with HIPAA.
5.2 Restrictions on Agent
Agent may not:
a. Make any financial decision unless separately authorized;
b. Execute a do-not-resuscitate order (DNR) contrary to Principal’s expressed wishes;
c. Consent to psychosurgery or sterilization unless explicitly authorized in Section 3.4 (d).
6. DEFAULT & REMEDIES
6.1 Events of Default
a. Gross negligence, willful misconduct, or breach of fiduciary duty by Agent;
b. Incapacity, resignation, or death of Agent with no Alternate Agent willing or able to serve.
6.2 Notice & Cure
Any interested person may deliver written notice of a suspected Event of Default to Agent. Agent shall have 48 hours to cure or respond before further action is taken.
6.3 Remedies
a. Petition to State Probate Court for removal of Agent and appointment of Alternate Agent or guardian;
b. Injunctive relief to enforce Principal’s healthcare directives;
c. Recovery of damages caused by Agent’s bad-faith or willful misconduct, including reasonable attorneys’ fees.
7. RISK ALLOCATION
7.1 Indemnification
Principal shall indemnify and hold harmless Agent from any liability, loss, or expense, including reasonable attorneys’ fees, arising from actions taken in Good Faith under this Agreement.
7.2 Limitation of Liability
Absent bad faith or intentional wrongdoing, Agent’s liability to Principal or third parties is limited to acts or omissions constituting gross negligence or willful misconduct.
7.3 Insurance
[OPTIONAL – GUIDANCE: Insert if Principal maintains liability insurance for fiduciaries.]
7.4 Force Majeure
Agent shall not be liable for failure to act when delayed or prevented by events beyond Agent’s reasonable control, provided Agent uses commercially reasonable efforts to overcome such impediments.
8. DISPUTE RESOLUTION
8.1 Governing Law
Per Section 1.3, this Agreement is governed by New York’s health-care decision statutes and common law principles.
8.2 Forum Selection
Any action or proceeding arising under or relating to this Agreement shall be brought exclusively in the [COUNTY] Surrogate’s Court or other court with probate jurisdiction in the State of New York.
8.3 Arbitration & Jury Trial
Arbitration and jury-trial waivers are intentionally omitted; statutory forums control.
8.4 Injunctive Relief
Nothing herein shall limit a party’s or interested person’s right to seek immediate injunctive or declaratory relief to enforce healthcare directives.
9. GENERAL PROVISIONS
9.1 Amendment & Waiver
This Agreement may be amended only by a written instrument signed by Principal and witnessed in the same manner as original execution. No waiver is effective unless in writing and signed by the waiving party.
9.2 Assignment
This Appointment is personal to Agent and may not be delegated or assigned.
9.3 Severability
If any provision is held invalid or unenforceable, the remainder remains in full force, and the invalid provision shall be reformed to the minimum extent necessary.
9.4 Effect of Divorce
[Default] Divorce or legal separation from Agent revokes Agent’s authority. Check box to override: ☐ Principal elects to maintain Agent’s authority notwithstanding divorce.
9.5 Entire Agreement
This document constitutes the complete and exclusive statement of Principal’s healthcare directive and supersedes all prior inconsistent directives.
9.6 Counterparts; Electronic Signatures
This Agreement may be executed in counterparts, each constituting an original, and via electronic signature in compliance with N.Y. State Technology Law § 304.
10. EXECUTION BLOCK
10.1 Principal’s Signature
| Principal: | [PRINCIPAL NAME] |
| Signature: | ________ |
| Date: | ________ |
10.2 Agent’s Acceptance
| Agent: | [AGENT NAME] |
| Signature: | ________ |
| Date: | ________ |
10.3 Alternate Agent(s) Acceptance (optional)
[Duplicate table for each Alternate Agent.]
10.4 Witness Attestation
We declare that the Principal appeared to execute this Healthcare Power of Attorney willingly, is personally known to us, and appears to be of sound mind and under no duress or undue influence.
| Witness #1 | Witness #2 |
|---|---|
| Name: [ ] | Name: [ ] |
| Address: [ ] | Address: [ ] |
| Signature: _______ | Signature: _______ |
| Date: ______ | Date: ______ |
[// GUIDANCE: New York requires at least TWO adult witnesses; neither may be the Agent or Alternate Agent.]
10.5 Notary Acknowledgment (Optional but recommended)
State of New York )
County of [ ] ) ss.:
On [DATE], before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to this instrument, and acknowledged executing the same for the purposes therein contained.
Notary Public
My Commission Expires: ____
[// GUIDANCE: Save executed originals in easily accessible locations and provide copies to your physician, designated Agent(s), and relevant healthcare facilities.]