HEALTH CARE PROXY-AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION IN NYS
Please highlight the blank space with a highlighted link to fill out the “HEALTH CARE PROXY-AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION IN NYS”
***************************************************************************************************
HEALTH CARE PROXY PRINCIPAL___________NAME OF AGENT___________
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
&
HEALTH CARE DECLARATION
(LIVING WILL)
NAME OF DECLARANT___________
DATED: April __, 2022
TO MY FAMILY, MY PHYSICIAN AND ALL OTHERS
TO WHOM IT MAY CONCERN
HEALTH CARE PROXY OF ___________
I. Appointment of Agent: I, ___________, hereby appoint ___________ as my Health Care Agent to make any and all health care decisions for me, except to the extent I state otherwise in this proxy.
II. I, ___________, hereby appoint ___________ as my Alternate Health Care Agent in the event that ___________ shall be unable to serve as my Health Care Agent.
This Health Care Proxy shall take effect in the event I become unable to make my own health care decisions as determined by the physician who has primary responsibility for my treatment.
III. Powers of Agent: I place great trust in ___________, and ___________, and to the fullest extent possible grant them the authority to act in any way which I myself could if I were personally present and able to act, without limiting my agent, I specifically allow them to do the following:
(A) To direct the withholding or withdrawal of all health care or of all life-sustaining treatment, including nutrition and hydration excepting only if needed to relieve suffering, severe discomfort or severe pain;
(B) To have access to and disclose medical records and other personal information, including protected health information (as that term is defined in HIPAA);
(C) To employ and discharge and to select and change physicians, care-givers, health care providers and facilities, and to arrange for my placement in or removal from any hospital, convalescent home, hospice, nursing home or other medical facility;
(D) To sign on my behalf any documents necessary to carry out the foregoing, including waivers or releases of liability required by any health care provider.
IV. Coordination With Living Will: I direct my agent to make health care decisions in accordance with my wishes and instructions as stated in my Health Care Decisions Declaration (Living Will) made this same day or as otherwise known to him or her. I also direct my agent to abide by any limitations on his or her authority as stated herein or as otherwise known to him or her. I have selected my Health Care Agent with the confidence that such person understands my feelings in these matters and will make the decision or decisions I will want made considering the circumstances as they exist at the time. It is my intention, therefore, that my Health Care Agent have full authority to make all health care decisions on my behalf and that the decision of my Health Care Agent be taken as a final and binding decision of mine, and will be the conclusive interpretation of the wishes I have made known in my Living Will.
V. Duration Of Powers: I understand that, unless I revoke it, this proxy will remain in effect indefinitely. Further, I understand that this proxy shall take effect when and if I become unable to make my own health care decisions.
VI. Third Party Reliance: To induce any third party to act hereunder, I hereby agree that any third party receiving an executed copy or a photocopy of this instrument may act hereunder, and that revocation or termination hereof shall be ineffective as to such third party unless and until actual notice or knowledge of such revocation or termination shall have been received by such third party.
VII. Indemnification Of Third Parties: I for myself and for my heirs, executors, legal representatives and assigns, hereby release and agree to indemnify and hold harmless any such third party from and against any and all claims that may arise against such third party by reason of such third party having relied on this instrument or the directions of my agent.
___________
Dated: April __, 2022
Address:
I declare that the person who signed this document is personally known to me; that she signed this document in my presence, and that she appears to be of sound mind and acted willingly and free from duress. I am not the person appointed as agent by this document.
Witness:______________________________________________
Address: _____________________________________________
Witness:______________________________________________
Address: _____________________________________________
My Agents’ Addresses and Phone Numbers.
Agent Name: ___________
Agent Address: ______________________________________
Agent Phone #: ( ) –
Alternate Agent Name: ___________
Alternate Agent Address: _________________________________
Alternate Agent Phone #: ( ) –
AUTHORIZATION FOR RELEASE OF
PROTECTED HEALTH INFORMATION (THE “AUTHORIZATION”)
I, ___________, intend to comply, now and in the future, with all requirements set forth in the Standards for Privacy of Individually Identifiable Health Information, known as the “Privacy Rule” which implements the privacy requirements of the Health Insurance Portability and Accountability Act of 1996, commonly known as “HIPAA” so that the information described below will be freely available to those described below. All provisions hereof shall be construed in accordance with that intent.
I hereby authorize each Covered Entity identified below to disclose my individually identifiable health information as described below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus (“HIV”) and Acquired Immune Deficiency Syndrome (“AIDS”), mental illness (except psychotherapy notes), chemical or alcohol dependency, laboratory test results, medical history, treatment, or any other such related information.
1. My Additional Identification Information:
Date of Birth: _____________
Social Security Number: _____________
2. Identity of Person or Class of Persons Authorized to Make Disclosure; Description of Information to Be Disclosed. I hereby authorize all covered entities as defined in HIPAA, and all other health care providers, health plans, and health care clearinghouses, including but not limited to each and every doctor, psychiatrist, psychologist, dentist, therapist, nurse, hospital, clinic, pharmacy, laboratory, ambulance service, assisted living facility, residential care facility, bed and board facility, nursing home, medical insurance company or any other medical provider or agent thereof having protected health information (as that term is defined in HIPAA), each being referred to herein as a “Covered Entity” to disclose the following information: All health care information, reports and/or records concerning my medical history, condition, diagnosis, testing, prognosis, treatment, billing information and identity of health care providers, whether past, present or future and any other information which is in any way related to my health care. Additionally, this disclosure shall include the ability to ask questions and discuss this protected medical information with the person or entity who has possession of the protected medical information even if I am fully competent to ask questions and discuss this matter at the time. It is my intention to give a full authorization as to ANY protected medical information to the persons named in this Authorization.
3. Person or Class of Persons to Whom the Covered Entity May Disclose the Above Described Protected Health Information. The above described information shall be disclosed to any person named as Health Care Agent or Alternate Health Care Agent in my Health Care Proxy executed on even date herewith, each such person being referred to herein as an “Authorized Person.”
4. Termination. This Authorization shall terminate on the first to occur of: (i) two (2) years following my death or (ii) upon my written revocation actually received by the Covered Entity. Proof of receipt of my written revocation may be either by certified mail, registered mail, facsimile, or any other receipt evidencing actual receipt by the Covered Entity. Such revocation shall be effective upon the actual receipt of the notice by the Covered Entity except to the extent that the Covered Entity has taken action in reliance on this Authorization.
5. Re-Disclosure; Indemnification. By signing this Authorization, I acknowledge that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the Authorized Person and the information once disclosed will no longer be protected by the rules created in HIPAA. No Covered Entity shall require an Authorized Person to indemnify the Covered Entity or agree to perform any act in order for the Covered Entity to comply with this Authorization.
6. Acknowledgment of Right to Treatment. I understand and hereby acknowledge that the Covered Entities may not condition my receipt of health care upon my execution of this Authorization, and I may refuse to sign this Authorization if I wish to do so.
7. Instructions to My Authorized Persons. My Authorized Person shall have the right to bring a legal action in any applicable form against any Covered Entity that refuses to recognize and accept this Authorization for the purposes that I have expressed. Additionally, my Authorized Person is authorized to sign any documents that such Authorized Person deems appropriate to obtain the protected medical information.
8. Revocation. This Authorization may be revoked in writing by me at any time.
9. Valid Document. A copy or facsimile of this original Authorization shall be accepted as though it was an original document.
10. My Waiver and Release. I hereby release any Covered Entity that acts in reliance on this Authorization from any liability that may accrue from releasing my protected medical information and for any actions taken by my Authorized Person. I also specifically prohibit my Authorized Person or any other person designated as my agent in any capacity from filing a complaint of any kind against any Covered Entity that complies with the directions of my Authorized Person hereunder related to disclosure of medical information to the extent that such a complaint purports to charge said Covered Entity with any violation of the Privacy Rules or other Federal or State laws related to disclosure of medical information as a result of their compliance with said directions.
Signed: April __, 2022
__________________________
___________
******************************************************************************
Please highlight the blank space with a highlighted link to fill out the “HEALTH CARE PROXY-AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION IN NYS”
LIVING WILL
This Health Care Decisions Declaration (Living Will) shall be effective to the extent permitted by law.
Declaration made this ___ day of April, 2022.
I, ___________, being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below.
FIRST: Heroic Medical Efforts: If at any time I should have an incurable injury, disease, illness or irreversible physical or mental condition certified to be a terminal condition by two (2) physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur in a short period of time whether or not life sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the performance of any medical procedure deemed necessary to provide me with comfort, care or to alleviate pain. Further, I direct that medication be mercifully administrated to me to alleviate suffering even though this may shorten my remaining life and retard my consciousness.
As an example of a few, but not all, of the measures of artificial life support in the face of impending death that I specifically refuse are:
(a) Artificial Respiration;
(b) Cardiopulmonary Resuscitation;
(c) Antibiotics;
(d) Artificial Nutrition and Hydration (nourishment and water provided by feeding tubes).
SECOND: Permanent Unconsciousness: If I should have an incurable or irreversible condition caused by injury, disease or illness, which causes me to be in a persistent vegetative state, certified to be such by two (2) physicians who have personally examined me, one (1) of whom shall be my attending physician, I direct that the application of life-sustaining measures, including nutrition and hydration, which would serve only to artificially prolong the moment of my death, be withheld or withdrawn, and that I be permitted to die naturally and with dignity. “Persistent vegetative state” shall mean a condition in which I show no evidence of verbal or non-verbal communication; demonstrate no purposeful movement or motor mobility; am unable to interact purposely with stimulation provided by my environment; am unable to provide for my own basic needs; and demonstrate all of the above for a period of time to be determined by my Health Care Agent, the decision of which shall be binding on all parties.
THIRD: Prolonged Care: In the event of prolonged illness, injury or disability, I would like to be maintained and cared for at home rather than in a hospital, nursing home or other medical facility, if it does not impose a burden on my family, emotionally or financially.
FOURTH: Careful Consideration Has Been Made: This statement is made after careful consideration and is in accordance with my strong convictions and beliefs. I want the wishes and directions expressed herein carried out to the extent permitted by law. It is my intention that this Living Will be honored by my family, attorneys, and physicians, and any sanitoria, nursing homes, health care facilities and temporary or permanent guardians as the final expression of my intent to refuse life-sustaining measures and acceptance of the consequences from such refusal. Insofar as they may not be legally enforceable, I hope that those to whom this Living Will is addressed will regard themselves as morally bound by these provisions. It is my wish and desire to die with whatever dignity is possible.
FIFTH: Morally Binding: I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. I recognize that this Living Will places a heavy burden of responsibility on my family and it is my intention of sharing that responsibility and of mitigating any feelings of guilt that this statement has made.
SIXTH: Third Party Reliance: I for myself and for my heirs, executors, legal representatives and assigns, hereby release and agree to indemnify and hold harmless any third party from and against any and all claims that may arise against such third party by reason of such third party having relied on this instrument of declaration.
SEVENTH: Coordination With Health Care Proxy: I recognize that a time may come when I cannot participate in any medical care decisions, even if there are favorable prospects for my eventual recovery. I know that it is not possible for me to anticipate the diverse medical decisions which may have to be made in the future and give specific written directions at this time. Accordingly, I have executed this Living Will and a Health Care Proxy. My agent under my Health Care Proxy is authorized to carry out my wishes as set forth herein. In the event that my wishes as expressed herein are unclear, subject to varying interpretations or are otherwise insufficient to address any medical situation which may arise, then I hereby direct that the decision of my agent, as named in my Health Care Proxy shall be final and binding on all parties.
EIGHTH: Anatomical Gifts: I do not wish to make anatomical gifts of any part of my body that my primary physician determines can be transplanted into another human being. _____________________________________
NINTH: Cremation: I direct that my body shall be cremated and that my ashes be disposed of as my Health Care Agent shall deem.________________________________________
Address: ____________________________________
I believe the declarant to be of sound mind. I did not sign the declarant’s signature above for or at the direction of the declarant. I am at least 21 years of age and am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession of the State of New York or under any Will of the declarant or codicil thereto, or directly financially responsible for declarant’s medical care. I am not the declarant’s attending physician, an employee of the attending physician, or an employee of the health facility in which the declarant is a patient.
Witness:______________________________________________
Address: _____________________________________________
Witness:______________________________________________
Address: _____________________________________________
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
