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Health care proxy is a legal document to outline a person's preferences and wishes concerning interventions.

Directly write your own Health Care Proxy here with no need to hire a lawyer

Jasper L. Edwards


Health care proxy is a legal document to outline a person's preferences and wishes concerning interventions, medical treatments and other issues related to health care. Policies may vary from state to state, but regardless of location, advance directives should always be included in each's medical records. Advanced directives typically fall into three categories:

• Do Not Resuscitate Order: This legal document, also known as DNR, is extremely valuable for determining end-of-life issues. A DNR order, however, is not legal until signed by the patient, a witness, and a physician. It should also be dated correctly and state whether the patient wants to be resuscitated or not if their heart stops beating.

• Living Will: This written document stipulates what kinds of medical treatment the patient recommends should they become incapacitated. It can be either general or very specific depending on the person and how adamant they are about their end-of-life care issues. The usual items outlined in a living will include: whether they wish to be on life support, receive tube feedings, length of time (if any) that they will stay on breathing machines, the individual that will make decisions on their behalf, etc.

• Durable Power of Attorney: This type of advance directive allows an individual the opportunity to designate someone, or many individuals, to act on their behalf for specific affairs.

When Should a Directive be created?

You will see an advanced medical directive used for several different situations-such as when someone is having major surgery, diagnosed with a life-threatening illness or is even becoming a single parent. Advance medical directives are extremely beneficial if an individual is unable to make his or her own medical decisions. Whatever the reason, all advance medical directives should be signed by an attorney and be notarized.

How to Obtain an Advance Medical Directive

Luckily, there are many ways that someone can obtain an advance medical directive. Many companies have booklets available, social workers and nurses usually have them on hand, and hospitals and attorneys also have copies of directives. It is worth the effort to ask for an advance medical directive as it will be invaluable during a medical dilemma. You can print off and copy a sample Health Care Proxy below this article.

To ensure that these directives are understood and followed in the right manner, certain precautions must be taken:

• These documents should be prepared in accordance with the applicable state rules and must comply with the Federal Health Insurance Portability and Accountability Act of 1996 or HIPAA.

• The contents of these documents should be shared and discussed with the appointed health care proxy or surrogate decision maker.

• Copies of the Advance Medical Directives should be provided to all the people concerned, such as the physician, the hospital, and family members.

• Extra copies of this document should be kept handy for use in emergencies, and your estate planning attorney should have a copy as well.

Health care proxy is an important piece of the estate planning puzzle. To learn more about creating advanced medical directives, you should contact a qualified estate planning attorney. Advanced Healthcare Directives are more precise than most boilerplate instructions Health care proxy should be one of your major your estate planning tools.


(Print off and fill in the blanks.)






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) Optional: 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):

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 this 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.

(5) Your Identification (please print) Your Name Your Signature Date Your Address

(6) Optional: Organ and/or Tissue Donation I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply)

¦ Any needed organs and/or tissues

¦ The following organs and/or tissues

¦ Limitations If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to 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.

Your Signature Date

(7) Statement by Witnesses

(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 is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence.

Witness 1


Name (print)



Witness 2


Name (print)



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