Health Care Proxy Workbook

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Introduction

Your HEALTH CARE AGENT is the person or persons you are granting legal authority to make health and medical decisions for you.

If you become unable, even temporarily, to make health care decisions, someone else must decide for you. Health care providers often look to family members for guidance. Family members may express what they think your wishes are related to a particular treatment.

However, in New York State, only a health care agent you appoint has the legal authority to make treatment decisions if you are unable to decide for yourself.

Your HEALTH CARE AGENT will also be authorized to obtain the release of all medical documentation and other information, including protected health information that you could personally obtain upon request, which could be in the possession of any health care provider, medical care facility, insurer, physician, hospital, ambulance service or nurse or any other covered entity under the Health Insurance Portability and Accountability Act of 1996 ("HIPPA").

Asterisks (*) indicate required answers.

If you should have any questions, feel free to call our office for help.

Your Information

Your Name *

Gender *

Male

Female

Address 1 *

Address 2

City *

State *

ZIP code *

Your Address *

Phone *

Health Care Agent Information

Health Care Agent Name *

Gender *

Male

Female

Country *

Address 1 *

Address 2

City *

State *

ZIP code *

Health Care Agent Address *

Phone *

(Optional) Alternative Health Care Agent Information

Add an Optional Alternative Health Care Agent

Yes

Alternative Health Care Agent Name

Gender

Male

Female

Country

Address 1

Address 2

City

State

ZIP code

Alternative Health Care Agent Address

Phone

Agreement

I understand “We The People”, (the Company)” will complete the document as stated on this receipt with information supplied by me for the purpose of representing myself, (Pro Se).

Any fees pursuant to this purchase are for computer time & document typing and do NOT include filing fees required by the court, state or any third party fees for providers, (e.g., courier fees, process servers, publications costs).

The Resource Attorney is available to answer "general" questions about the law, the Resource Attorney will NOT provide legal advice or represent you in court. The Resource Attorney is NOT an employee of The Company.

I hereby agree to assume all responsibility associated with the information in the preparation of the documents. I further agree to read and approve all documents prior to signing. If any disputes arise between the parties hereto, venue shall lie in ALBANY COUNTY, State of New York. In consideration of the foregoing, I make my authorization.

The Company will use its best efforts to prepare documents in a timely fashion; no guarantee has been made regarding the time of completion and/or filing of documents on my behalf. I further understand that The Company has made NO representations regarding the successful outcome (or otherwise) of my legal matter.

The aforementioned as well as the following terms are understood and agreed by “The Company" and me therefore by signing below, I understand and acknowledge the all of the terms contained in this contract:

The Company is not a law firm & its owners/staff members are NOT lawyers.
The Company cannot select legal documents for me.
The Company cannot represent me in court.
The Company cannot advise me about my legal rights or the law.
I am solely responsible for the information provided for the preparation of the documents.
If cancellations are requested, The Company will retain a $25.00 cancellation fee to cover administrative costs.
If I provide The Company with inaccurate information or if document changes are requested for any reason by me, the court or state, an amendment fee will be charged accordingly for retyping (fees range from $25.00 - $39.00 per request).
There are NO refunds once documents are typed.
I must pick up the completed forms within 30 days from the date of notification by The Company. If I am unavailable or unreachable, I have the responsibility of calling or coming in to the office within 20 business days after such notification or 20 business days after my last dealing/communication with the office in order to inquire as to my document status.

Agree *

I agree with the terms of the agreement and I HAVE REVIEWED MY WORKBOOK ANSWERS FOR ACCURACY TO AVOID CORRECTION FEES.

Certification *

The above answers were provided by me and I did not receive any legal advice from WTP personnel in completing my forms.

Acknowledge *

Once I click the Buy Now button, I will not be able to edit the workbook.

If I haven't checked out, I can remove the workbook from my cart and start again.

If I have checked out, I will have to contact We the People's office and will incur change fees.

Customer Signature Here *

Date *

Month

Day

Year

Services

NYS Health Care Proxy [$99.00]

Health Care Proxy *

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