Fillable Form Health Care Proxy

What is a Healthcare Proxy Form?

A Healthcare Proxy Form is a legal document used to appoint another person as a proxy or agent, which gives them the right to make decisions on a person’s behalf with regards to healthcare should they be unable to make a decision themselves for any reason. In the case of a minor, a Healthcare Proxy Form for a Minor is needed to assign the responsibility of medical decisions to another person if their immediate family or guardian is not available or present.

When a person falls ill or is injured and must be sent to the hospital, certain medical decisions may have to be made depending on the severity of their disease or injury. These decisions are usually related to surgical procedures or medication, and will (assuming that the patient is of age) be left to the patient to make a decision by default. However, in the case that the patient is unable to make their own decisions or that medical professionals are not certain that the patient is of sound mind to be able to make a proper decision, the responsibility of the choice then falls to a person’s next of kin (their closest immediate family member(s)) or their assigned Healthcare Proxy.

A Healthcare Proxy may also be called a medical power of attorney, or an appointed health care agent or surrogate. It differs from a Living Will in that a Living Will allows a person to declare what treatments they wish to or do not wish to undergo, and does not give anyone else the authority to actually make medical decisions on a person’s behalf, while a Healthcare Proxy is given the authority to make medical decisions in certain situations.

When filling out a Healthcare Proxy blank form, make sure that the person you are appointing as your Healthcare proxy is aware of the following:

• Your personal attitudes towards health, illness, death, and dying
• Your preferences or needs with regards to healthcare
• Your religious beliefs
• Your feelings on health care providers, institutions, and caregivers.

It is also generally advised to have an “alternate” Healthcare Proxy in mind, to serve as a backup in the event that the originally appointed proxy is not available. To be considered valid, the signing and filling out of a Healthcare Proxy form must be witnessed by two people who are not the assigned agent or the person filling out the form.

Who needs to use a Healthcare Proxy Form?

Any person who wishes to grant another person or persons the power to make decisions on their behalf regarding medical care must fill out a generic Healthcare Proxy form. It is important to fill out the form as soon as possible if one wishes to appoint anyone other than their next of kin as having the authority to make medical decisions on their behalf to ensure that the document can be properly noted and recognized as valid when it is needed.

How to fill out a Healthcare Proxy Form?

The Healthcare Proxy form is a very simple form to fill out. Make sure to download it in PDF before printing it so as to preserve its format and contents.

If more information or details on particular steps are needed, you may consult the instructions for the Healthcare Proxy form on Page 1 of the document.

Line 1 - Name

Enter your full legal name, with no abbreviations.

Line 1 - Name, Home Address, and Phone Number of Appointee

Enter the full legal name, primary address, and primary phone number of the person you are appointing as your Healthcare Proxy. Note that the proxy will only take effect if you are unable to make your own health care decisions, and only to the extent that you say otherwise.

Line 2 - Optional: Alternate Agent

Enter the full legal name, primary address, and primary phone number of the person you are appointing as the alternate Healthcare Proxy or agent in the case that the originally appointed proxy is not available.

Line 3 - Duration of Proxy

If you wish to assign an expiration date for the proxy, or you wish to make a proxy expire, state the date of expiration and any conditions that must be fulfilled for the proxy to expire.

Line 4 - Optional: Extent of Authority

If you wish to place limitations on the decisions that your assigned Healthcare Proxy may make on your behalf, state your wishes or limitations. Attach additional pages as necessary.

Line 5 - Identification: Name

Enter your full legal name.

Line 5 - Identification: Signature

Sign the form in the space provided.

Line 5 - Identification: Date

Enter the date that the form was signed.

Line 5 - Identification: Address

Enter your primary address.

Line 6 - Optional: Organ and/or Tissue Donation

If you wish to make any anatomical gift or donation in the event of your death, check all of the following boxes that apply:

• Any needed organs or tissues
• The following organs or tissues (specify in the space provided)
  • Limitations (Enter any limitations you have placed on the donation of the above-indicated organs or tissues)

Then enter your signature on the space provided and enter the date that the form was signed.

Line 7 - Statement by Witness

Witness 1

Date

Enter the date that the form was signed in front of the witness.

Name

Enter the full legal name of the witness.

Signature

Have the witness sign the form in the space provided.

Address

Enter the primary address of the witness.

Witness 2

Date

Enter the date that the form was signed in front of the witness.

Name

Enter the full legal name of the witness.

Signature

Have the witness sign the form in the space provided.

Address

Enter the primary address of the witness.

Tips when filling out a Healthcare Proxy Form

Filling out a generic Healthcare Proxy form is very simple. However, it is important that all of the information entered is correct and updated, as the form involves giving a person the authority to make medical decisions on your behalf based on what you have written on the form.

Keep the form in a safe and secure place. Make sure to store the accomplished form in an organized and secure area. This will help to make sure that it is available to consult when needed, and that issues such as identity theft and fraud are avoided.

Practice good contract management. Create multiple copies of the form, and store the original copy as well as any others not distributed to the assigned proxies, healthcare professionals, or other related people, in a safe and secure area. This is important to make sure that the relevant people are notified of your decision, and that there are extra copies of the form that may be used in the event that a person’s copy is lost or otherwise inaccessible.