New York Medical Power of Attorney
This Medical Power of Attorney is created in accordance with the laws of the State of New York.
Principal's Information:
- Full Name: ______________________________________
- Address: _________________________________________
- City, State, Zip Code: ____________________________
- Date of Birth: ____________________________________
Agent's Information:
- Full Name: ______________________________________
- Address: _________________________________________
- City, State, Zip Code: ____________________________
- Phone Number: ___________________________________
Grant of Authority:
I, _____________________, hereby designate the individual named as my agent to make medical decisions on my behalf in the event I am unable to do so.
Agent's Powers:
- To make decisions regarding my medical treatment
- To access my medical records and health information
- To make decisions about life-sustaining treatment
Effective Date:
This Medical Power of Attorney shall become effective on the date I sign it, unless otherwise specified:
Date: _______________________
Witness Signatures:
This document must be signed in the presence of two witnesses who are not related to the Principal or the Agent:
- Witness 1: ___________________________ Signature: _______________________ Date: ____________
- Witness 2: ___________________________ Signature: _______________________ Date: ____________
Notary Public:
State of New York, County of _____________
On the _____ day of ___________, 20____, before me, the undersigned, a Notary Public, personally appeared ________________________, who is known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he/she executed the same.
Notary Public Signature: ______________________ Notary Seal: ______________________
This document is intended to empower the designated agent to act in my best interests regarding healthcare decisions.