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Cardiac Surgery Report, Adult (age 18 and over) NEW YORK STATE DEPARTMENT OF HEALTH State Cardiac Advisory Committee Facility Name PCI Number Sequence Number I. Patient Information Patient Name (last)

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What is health care proxy form?

A health care proxy form is a legal document that allows an individual to appoint someone to make medical decisions on their behalf if they become unable to do so.

Who is required to file health care proxy form?

Anyone who wishes to appoint a health care agent to make medical decisions on their behalf should file a health care proxy form.

How to fill out health care proxy form?

To fill out a health care proxy form, you need to provide your personal information, choose a health care agent, and sign the form in the presence of witnesses or a notary public.

What is the purpose of health care proxy form?

The purpose of a health care proxy form is to ensure that an individual's medical treatment preferences are honored and that they have someone they trust to make medical decisions for them.

What information must be reported on health care proxy form?

A health care proxy form typically requires the individual's name, contact information, the name of the chosen health care agent, and any specific instructions or preferences regarding medical treatment.

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