Get the Health Care Proxy form and instructions

Things you should know before starting

Clarify your values and beliefs

Before you complete this form you should try to clarify your values and beliefs, if you haven't already.

Here are some questions for you to consider that may be helpful:

• What contributes to the quality of life you want?
• How do you want to spend your final years, weeks or days?
• What activities are essential to having a quality life?
• What role does your faith play in making these decisions?

Use them to frame your medical wishes

Now you can frame your medical wishes around your answers to these questions. Based on your answers to the questions above:

• Which treatments are you willing to accept?
• Are there any treatmens you would never want?
• How much medical care are you willing to to have to stay alive?
• What kind of medical risks are you willing to take?
• When would you want to shift from treatment to care that only relievs pain?

Have honest conversations

Here are some people you should discuss your medical wishes with:

• Your family, or those closest to you 
• The person you are planning on naming as your health care agent
• Your health care providers

If you haven't already chosen a health care agent, these conversations may help you figure out who is most likely to best represent your wishes.

This information has been summarized from recommendations provided by the NY State Health Department on choosing a health care agent.

What to do next

You can print the form and fill it out by hand or fill out the form on your computer and then click print to get a typed version.

If you choose to fill it out on the computer and then print the typed version, do not type in initials or signatures. 

Go back to the guide

This resource is part of a longer guide on legal planning documents. If you just landed here, click here to go back to the guide to learn more about power of attorney and other legal planning documents you may want to prepare.