Healthcare Proxy

Full Legal Name *

Use your name exactly as it appears on your government-issued ID.

Date of Birth *

Governing State *

Residential Address *

Legal Restriction: Your healthcare agent cannot be your treating physician, nurse, or any employee of your treating healthcare facility - unless they are related to you by blood or marriage. Naming a provider creates a conflict of interest that courts will void.

Choose carefully. Your Agent will make life-critical decisions on your behalf. Select someone you trust completely who knows your values - a spouse, adult child, sibling, or close friend. They must be at least 18 years old and mentally competent.

Agent's Full Legal Name *

Agent's Address *

Agent's Phone *

Hospitals call this number in emergencies.

Agent's Email (recommended)

Relationship to You

When Does Agent Authority Begin?

Your Agent's authority activates only when your attending physician certifies in writing that you lack the capacity to make or communicate healthcare decisions. Until then, you retain full control.

Include Mental Health Treatment Decisions?

If included, your Agent may authorize voluntary admission to psychiatric facilities and consent to or refuse mental health treatment. Some states require explicit language for this authority.

Provide Specific End-of-Life Instructions?

If you provide instructions, they guide your Agent and physicians. Your Agent may not override explicit instructions without a court order.

Note: These preferences are legally documented instructions for your Agent and treating physicians. They do not constitute a physician-signed DNR or POLST order - your treating physician must separately execute those clinical orders, ideally in consultation with your Agent.

CPR / Cardiopulmonary Resuscitation

Mechanical Ventilation (Breathing Machine)

Artificial Nutrition & Hydration (Feeding Tube / IV)

Artificial nutrition means feeding tubes or intravenous nutrition if you cannot eat/drink on your own. Cruzan v. Director (1990) established the constitutional right to refuse this treatment.

Kidney Dialysis

Pain Management & Comfort Care

"Maximize Comfort" means palliative / hospice-level pain control, even if it may hasten death. "Standard Care" means routine hospital pain management.

Critical: Under federal HIPAA law, hospitals may legally refuse to share your medical records with your Agent - even if they hold a Healthcare Proxy - unless you include an explicit HIPAA authorization designating them as your Personal Representative (45 C.F.R. §164.502(g)). Without this, your Agent could be blocked from information needed to make informed decisions. Strongly recommended.

Include HIPAA Personal Representative Authorization?

This authorization is effective immediately upon signing, even before any incapacity determination - allowing your Agent to coordinate care and access records at any time.

If your primary Agent is deceased, incapacitated, unwilling, or unreachable at the critical moment - what happens? A Successor Agent ensures the document never goes void.

Name a Successor Agent?

Successor's Full Legal Name *

Successor's Phone *

Relationship to You

Successor's Address

Organ & Tissue Donation

Pursuant to the Uniform Anatomical Gift Act (UAGA 2006). If not specified here, your state's donor registry and family wishes apply.

Autopsy

If you object, note that a coroner or medical examiner may order an autopsy regardless of your wishes when required by law.

Remains / Funeral Preference

Additional Funeral or Memorial Instructions (optional)