Healthcare Proxy Forms

A couple who’ve been together for 18 years went on vacation, on a cruise, with three of their four children. One of them had a massive stroke as their ship was about to leave port, which meant she received medical care at Miami’s Jackson Memorial Hospital, where her partner was told the couple made the mistake of being in “an anti-gay city and state” and refused to let her partner in to see her, but for five minutes, as she was dying.

She died about 18 hours later. Both women were only 39 years old.

This is what DOMA & all this other anti-gay bullshit leads to, but please queer folks, fill out your healthcare proxies. You can find NYS’s here, and here in .pdf format. If people have or find links for these forms in their state, please post them below, or send them to me via email & I can post them.

More instructions and state-specific forms below the break.



Health care forms may differ in structure from state to state and pre-made forms are not compulsory as long as certain guidelines are met. The common guidelines include:[3]

  • Name and address of the agent.
  • Name and address of an alternate agent.
  • Duration of the proxy – not indicating a duration means it’s valid unless stated otherwise.
  • Special instructions – these can broaden or limit the powers of the agent. If the patient doesn’t want to be on feeding tubes no matter what, this can be stated here. If there are certain treatments that the patient doesn’t want to receive like dialysis or blood transfusion, then they must be indicated. However, if the patient wants to give the agent more flexibility with some or no restriction, this must be written.
  • Name, date and signature of the primary individual.
  • Instructions on tissue or organ donation.
  • Two adult witnesses must sign the document stating that they have witnessed this agreement and that both parties appear to be sane. The witnesses must be 18 years or older. The agent and primary individual do not qualify as witnesses.
  • Presence of a lawyer – such a person may help in drafting a document tailored to the needs of the primary individual.
  • Once signed, copies of the form must be given to health care providers, the agent, spouse, and close friends. A copy should also be carried by the primary individual (in wallet or purse)…ing-wills.html…9/292/295/ART/…_attorney.html

(Thanks to Donna T, Dana, Donna, & Joanne for the help)

2 Replies to “Healthcare Proxy Forms”

Comments are closed.