This is an important legal form. Before signing this
form, you should understand the following facts:
- This forms gives the person you choose as your agent the
authority to make all health care decisions for you, except to the
extent you say otherwise in this form, "Health care" means any
treatment, service or procedure to diagnose or treat your physical
or mental condition.
- Unless you say otherwise, your agent will be allowed to make
all health care decisions for you, including decisions to remove or
provide life-sustaining treatment.
- Unless your agent knows your wishes about artificial nutrition
and hydration (nourishment and water provided by a feeding tube),
he or she will not be allowed to refuse or consent to those measure
- Your agent will start making decisions for you when doctors
decide that you are not able to make health care decisions for
Talk about choosing an agent with your family and/or close
friends. You should discuss this form with a doctor or another
health care professional, such as a nurse or social worker, before
you sign it to make sure that you understand the types of decisions
that may be made for you. You may also wish to give your doctor a
signed copy. You do not need a lawyer to fill out this
You can choose any adult (over 18), including a family member,
or close friend, to be your agent. If you select a doctor as your
agent, he or she may have to choose between acting as your agent or
as your attending doctor; a physician cannot do both at the same
time. Also, if you are a patient or resident of a hospital, nursing
home or mental hygiene facility, there are special restrictions
about naming someone who works for that facility as your agent. You
should ask staff at the facility to explain those restrictions.
You should tell the person you choose that he or she will be
your health care agent. You should discuss your health care wishes
and this form with your agent. Be sure to give him or her a signed
copy. You agent cannot be sued for health care decisions made in
Even after you have signed this form, you have the right to make
health care decisions for yourself as long as you are able to do
so, and treatment cannot be given to you or stopped if you object.
You can cancel the control given to your agent by telling him or
her or your health care provider orally or in writing.