Sample Health Care Proxy Affidavit

I, [Name]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 only when and if I become unable to make my own health care decisions.

(2) Optional: Alternate Agent

If the person I appoint is unable, unwilling or unavailable to act as my health care agent, 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.

(3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall remain in effect indefinitely. (Optional: If you want this proxy to expire, state the date or conditions here.) This proxy shall expire (specify date or conditions): _____________________________________

_____________________________________

_____________________________________

(4) I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows or as stated below. (If you want to limit your agent’s authority to make health care decisions for you or to give specific instructions, you may state your wishes or limitations here.) I direct my health care agent to make health care decisions in accordance with the following limitations and/or instructions (attach additional pages as necessary):

_____________________________________

_____________________________________

_____________________________________

Please note that in order for your agent to make health care decisions for you about artificial nutrition and hydration (nourishment and water provided by feeding tube and intravenous line), your agent must reasonably know your wishes. You can either tell your agent what your wishes are or include them in the above section. See instructions for sample language that you could use if you choose to include your wishes on this form, including your wishes about artificial nutrition and hydration.

Health Care Proxy, 2

(5) I also grant authority and power to my agent(s) to serve as my personal representative for purposes of the Health Insurance Portability and Accountability Act (HIPAA). My agent is authorized to execute any and all releases and other documents necessary in order to obtain disclosure of my patient records and other medical information subject to and protected by HIPAA.
(6) Your Identification (please print)
Name_____________________________________
Signature ______________Date ________________
Address___________________________________
(7) Witnesses: Two witnesses must be 18 years of age or older and cannot be the health care agent or alternate.
I declare that the person who signed this document appeared to execute the Health Care Proxy willinglyand free from duress. He or she signed (or asked another to sign for him or her) this document in my presence.
Witness 1:
Witness 2:
Signature:_________________  Signature: __________________
Print Name: ________________________________
Print Name: _______________________________
Address: __________________________________
Address: _________________________________
Tel. No.: __________________________________
Tel. No.: _________________________________
Optional: Organ and/or Tissue Donation
You may state wishes or instructions about organ and/or tissue donation on this form. A health care agent cannot make a decision about organ and/or tissue donation because the agent's authority ends upon your death. The law does provide for certain individuals in order of priority to consent to an organ and/or tissue donation on your behalf: your spouse, a son or daughter 18 years of age or older, either of your parents, a brother or sister 18 years of age or older, a guardian appointed by a court prior to the donor's death, or any other legally authorized person.
I hereby make an anatomical gift, to be effective upon my death, of (write your initials next to the statement of your choice):
Any organs and/or tissues
The following organs and/or tissues:
__________________________________
__________________________________
Limitations:
__________________________________
__________________________________

If you do not state your wishes or instructions regarding organ and/or tissue donation on this form, it will not mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.
Signed ___________________________ Date: ____________________________
Address:__________________________