New York Living Will Template
This Living Will is created in accordance with New York State laws regarding advance healthcare directives. It details your wishes regarding medical treatment when you are no longer able to communicate them yourself.
Personal Information:
- Full Name: ____________________________
- Date of Birth: ____________________________
- Address: ______________________________
- Phone Number: ________________________
- Email Address: ________________________
Declaration:
I, ____________________________, being of sound mind, do hereby declare this Living Will as my Health Care Directive. This document states that if I become unable to communicate my wishes regarding medical treatment due to my medical condition, I wish the following:
Medical Procedures:
- I do not wish to receive life-sustaining treatment if my condition is terminal. My definition of terminal is as follows: ________________________.
- If I am in a persistent vegetative state or have an irreversible condition, I do not want any medical procedures that would prolong my life.
- However, I do wish to receive palliative care to relieve pain and suffering.
Appointment of Health Care Agent:
I hereby appoint ________________________ as my Health Care Agent. If this person is unable or unwilling to act, I appoint ________________________ as an alternate agent.
Health Care Agent Responsibilities:
- To make medical decisions on my behalf based on my wishes and best interests.
- To have access to all my medical records and information.
- To consult with healthcare providers about treatment options and make decisions accordingly.
Signatures:
By signing below, I confirm that I am making this Living Will voluntarily and understand its contents.
Signature: _______________________________
Date: ____________________________
Witness Information:
This document must be signed in the presence of at least 2 witnesses who are not related to me and who are not my Health Care Agent.
- Witness 1 Name: ________________________
- Witness 1 Signature: ________________________
- Date: ____________________________
- Witness 2 Name: ________________________
- Witness 2 Signature: ________________________
- Date: ____________________________
Make sure to discuss your Living Will with family members and healthcare providers. Keep a copy of this document in a safe place and share it with your appointed Health Care Agent.