VNA of Hudson Valley Phone: 914-666-7616
VNA of Hudson Valley Hospice Main Image
Home About Us Our Services In The News Publications Events For Caregivers Volunteer Donate
Banner Hospice Care in Westchester and Putnam; home health care
Health Care Proxy
About the Health Care Proxy Form
FAQs - Health Care Proxy Forms
Health Care Proxy Instructions
Additional Resources
Frequently Asked Questions
Bereavement Support Groups
Employment Opportunities

Health Care Proxy

Health Care Proxy Instructions

Item (1)

Write the name, home address and telephone number of the person you are selecting as your agent.

Item (2)

If you want to appoint an alternate agent, write the name, home address and telephone number of the person you are selecting as your alternate agent.

Item (3)

Your Health Care Proxy will remain valid indefinitely unless you set an expiration date or condition for its expiration. This section is optional and should be filled in only if you want your Health Care Proxy to expire.

Item (4)

If you have special instructions for your agent, write them here. Also, if you wish to limit your agent's authority in any way, you may say so here or discuss them with your health care agent. If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decision to consent to or refuse life-sustaining treatment.

If you want to give your agent broad authority, you may do so right on the form. Simply write:
I have discussed my wishes with my health care agent and alternate and they know my wishes including those about artificial nutrition and hydration.

If you wish to make more specific instructions, you could say:
If I become terminally ill, I do/don't want to receive the following types of treatments....

If I am in a coma or have little conscious understanding, with no hope of recovery, then I do/ don't want the following types of treatments:....

If I have brain damage or a brain disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, I do/don't want the following types of treatments:....

I have discussed with my agent my wishes about____________ and I want my agent to make all decisions about these measures.

Examples of medical treatments about which you may wish to give your agent special instructions are listed below. This is not a complete list:







  • artificial respiration 
  • artificial nutrition and hydration (nourishment and water provided by feeding tube) 
  • cardiopulmonary resuscitation (CPR) 
  • antipsychotic medication 
  • electric shock therapy 
  • antibiotics 
  • surgical procedures 
  • dialysis 
  • transplantation 
  • blood transfusions 
  • abortion 
  • sterilization

Item (5)

You must date and sign this Health Care Proxy form. If you are unable to sign yourself, you may direct someone else to sign in your presence. Be sure to include your address.

Item (6)

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.

Item (7)

Two witnesses 18 years of age or older must sign this Health Care Proxy form. The person who is appointed your agent or alternate agent cannot sign as a witness.




Home | About Us | Gift Opportunities | Our Services | Events | For Caregivers | Volunteer | Careers | Contact Us
©2019 by VNA of Hudson Valley. All Rights Reserved. Terms of Use | Privacy Policy

Website Design & Digital Marketing by Deluge Interactive
Managed IT Services by Delaney Computer Services, Inc.

site by Delaney Computer Services: Rockland County IT Managed Service, Tech Support and Web