New York Health Care Proxy Form

Jurisdiction: New York
Purpose: Medical & health care
Source / form version: Form 1430, printed 7/12; eight-page instructions and form
Resource format: PDF
Signing: Sign and date before two adult witnesses; the agent and alternate cannot witness. Ordinary execution does not require a notary.

Preview PDF

Open the preview to load the complete document. If it does not display, use the direct link below.

Sources checked: 2026-11-13. General information, not individual legal advice.

Read the instructions before the form

The downloadable packet contains New York’s Department of Health explanation and health care proxy. It appoints a primary agent and optional alternate. You may state limits, set an expiration date, and give directions for decisions the agent may face. The copy is hosted by NYU Langone and is printed 7/12; it is not represented as a newly revised edition.

Sources: [1] [4] [2] [3]

Discuss artificial nutrition and hydration

New York places particular importance on the agent knowing your wishes about artificially supplied nutrition and hydration. Discuss those wishes explicitly and consider recording them. The agent should also understand your values, goals, and treatment limits, because not every future medical situation can be predicted in a form. Optional organ-donation information serves a different purpose from the appointment itself.

Sources: [1] [4] [2] [3]

Witness and distribute the signed proxy

Use two adults who are not the agent or alternate and follow the witness statement printed with the form. Keep the completed appointment and any instructions together. Give copies to the agent, alternate, primary care provider and other treating facilities. Your agent acts after the applicable clinical determination of incapacity; you continue to make your own decisions when capable. Certain mental-health or developmental-disability settings have additional execution or determination rules, so ask the facility before signing there.

Sources: [1] [2] [3]

Common questions

Can I use this health care proxy for financial decisions?

No. It appoints a health care decision-maker. Financial and property powers require a separate financial power of attorney.

Sources: [2] [1]

Related forms and guides

Sources and verification

NYUhostHTTP200; eight-pageDOH1430PDFdownloaded and inspected, footer7/12. Originalhealth.ny.gov/publications/1430.pdf blockedautomatedfetch403;NYUprimaryhealthsystemmirrorselected. CheckofficialDOHsourcepagefornewereditions.

The date above records a source check. It does not certify that a form is suitable for your circumstances or that an attorney has reviewed your document. Read the publisher’s current instructions before use.