Regardless of the choices i have made in this form and except as i state in the following space, i direct that the best medical care possible to keep me clean, comfortable and free of pain. An advance directive can also be used to say what your preferences are about treatments that might be used to sustain your life. District of columbia advance health care directive this is a legal form that lets you have a voice in your health care. Caring connections, a program of the national hospice and palliative care organization nhpco, is a national consumer engagement initiative to improve care at the. Advance directives texas health and human services. Advance directives washington state medical association. These instructions reflect my commitment to decline medical treatment under the circumstances indicated below. Give to your family and anyone else who might be involved in your care a copy of your advance directive and discuss it with them. Alaska legal services corporation alsc provides this as a service to you and does not take responsibility for how you fill it out. If my attending physician and another physician determine that i am no longer able to make decisions regarding. This form satisfies the requirements of virginias health care decisions act. The form combines a medical power of attorney and living will that only becomes ineffect upon the patients incapacitation or not being able to think for themselves. This is true even under the most serious medical conditions.
Caringinfo provides free advance directives and instructions for each state that can be opened as a pdf portable document format file. Sign here for the health care medical power of attorney andor the health care directive forms. The state offers a form to do this planning, inclu ded with this pamphlet. Other forms of advance directives for health care may be used in georgia. Advance directive is the general term that refers to the various documents that could include a living will, instruction directive, health care proxy or health care power of attorney. I understand that under texas law this directive has no effect if i have been diagnosed as pregnant. This directive becomes effective if you have a terminal condition. Writing down your preferences is a good way to start planning for your health care.
You need to sign and date your new advance directive and have two witnesses sign and date it. Advance directive for health care living will and health care proxy this form may be used in the state of alabama to make your wishes known about what medical treatment or other care you would or would not want if you become too sick to speak for yourself. Alaska advance health care directive this booklet contains the alaska statutory form for an advance health care directive. Yes, you can change your advance directive any time you want by completing a new one. Advanced health care directive form attorney general of. A health care directive living will is a form you use to explain what you want andor do not want concerning your medical care. Using this form of advance directive for health care is completely optional. Sentara healthcare and the sentara center for healthcare ethics are offering the community the opportunity to complete their advance care plan advance directive and register it, free of charge, with our national advance directive registry through the u. I have created this document with much thought to give my treatment choices and personal preferences if i cannot communicate my wishes or make my own health care. Advance directive is a term that refers to your spoken and written instructions about your future medical care and treatment. When you complete this form, its important that you also talk to your doctor, family, and other loved ones who.
Advance health care directive forms 4700 4701 chapter 2 added by stats. An advance directive is a written statement you prepare that expresses how you want medical decisions made in the future should you not be able to make them yourself. I do i do not circle one and cross out the other want either cardiopulmonary resuscitation manual or mechanical efforts to restore heartbeat or breathing after they. An advance directive is a written document in which you specify what type of medical care you want in the future, or who you want to make decisions for you, should you lose the ability to make decisions for yourself. The difference between this advance directive form and the living will and durable power of attorney for health care the georgia advance directive for health care is an attempt to combine. When planning for your future medical care, prepare your advance directives to be sure your loved ones make health choices according to your wishes. Health care directive living will this package contains a health care directive sometimes known as a living will for the state of washington. The form as a whole is called maryland advance directive. Health care directive forms are provided but in the case where none is provided, the patient may create their own as long as they contain particular details. Consult an attorney if you need legal advice of any nature. Advance health care directive california probate code section 4701 explanation you have the right to give instructions about your own health care. The person making the advance medical directive should complete this form and send it in a sealed envelope by mail or by hand to the registrar of advance medical directives at the address given below.
Any paperwork given by the hospital such as health care claim forms, medical record forms, and medical intake form usually follow a standardized format. If i fail to designate a health care proxy in this section, i am deliberately declining to designate a health care proxy. The advance health care directive form lets you do one or both of these things. These illness may be a coma or permanent unconsciousness for example. Durable power of attorney for health care and living will file type.
By stating your health care choices in an advance directive, you help your family and physician understand your wishes about your medical care. Advance directives planning for medical care in the event of loss of decisionmaking ability durable power of attorney for health care. Free living will forms advance directive pdf word eforms. If you wish to only use the medical power of attorney, strike an x through this section. Create a free advance directive form to designate a health care representative and your endoflife medical decisions if you become unable to communicate. Free north carolina living will forms advance health care. The form in this pamphlet allows a patient advocate to have access to your medical records at any time after you appoint him or her. If you only want to make your own health care choicesgo to part 2 on page 6. If you only want a health care medical power of attorney, draw a large x through this page. You can give your agent virtually all the powers you currently have to transact business and make medical decisions, including the power to. It is a form that would allow you to make your healthcare decisions for you when you are already unable to do so. Form 31 advance health care directive instructions part 1 of this form lets you name another individual as agent to make health care decisions for you if you become incapable of making. Health care directive and that you expect them to honor your wishes.
Indiana law pays special attention to advance directives. The attached forms are provided as is and are not the substitute for the advice of an attorney. They will place the document in careconnect, uclas electronic health record. A health care directive is a document where the patients writes down their wishes regarding their treatment and health care. Yes, you can cancel your advance directive any time you want. If you have completed an advance directive in the past, this new advance directive will replace any older directive. These forms are not intended and are not a substitute for legal advice.
You dont have to use a form, but your health care directive must meet the following requirements to be legal. Advance health care directive form instructions an impossible. I want the following person to make health care decisions for me. Advance directive is the general term that refers to the various documents that could include a living will, instruction directive. The pdf form in english must be properly executed in accordance with the instructions on the opposite side download spanish instructions separately to be considered a valid form by emergency medical services personnel.
I have the right to choose to not do an advance directive at all. Living wills and advance directives for medical decisions. This document combines a health care directive, which is your living will, along with a medical power of attorney to appoint an agent. If you only want to name a medical decision maker go to part 1 on page 3. It will let your family, friends, and medical providers know how you want to be cared for if you cannot speak for yourself.
The washington advance directive allows a resident of the state to elect someone else to handle their medical decisions on their behalf as well as outlining their endoflife treatment options. Advance directive state of oregon this form may be used in oregon to choose a person to make health care decisions for you if you become too sick to speak for yourself. This release authority applies to any information governed by the health insurance portability and accountability act of 1996 aka hipaa, 42 usc 1420d and 45 cfr 160164. You also have the right to name someone else to make health care decisions for you. Pennsylvania advance health care directive 2 always sign the form in part 3 on page 9. Your advance directives will not take away your right to decide your current health care. California advance health care directive if you only want a health care agent go to part 1 on page 3.
I request all health care providers who care for me to honor this directive. Following your, colorado advance medical directive is a colorado organ donation form, which allows you to set out your wishes regarding organ donation. If your preferences change, complete a new georgia advance directive for health care. The term advance directive refers to your oral and written instructions about your future medical care in the event you are unable to express your medical wishes. Nevada advance health care directive this is a legal form that lets you have a voice in your health care. The statutory advance health care directive form is as follows. Advance directives living will and durable power of. Advanced health care directive form state of california. An advance health directive is a document that states your wishes or directions regarding your future health care for various medical conditions.
This directive will remain in effect until i revoke it. Preparing a few simple legal forms known as advance directives can help ensure that your wishes are respected and that your health care decisions stay in the hands of people you trust. This form lets you do either or both of these things. Preparing a few simple legal forms known as advance directives can help ensure that your wishes are respected and that your health care. Download living will forms advance health care directives. Give the new form to your medical decision maker and medical providers. Just select your state from the dropdown menu below and download the free advance directive forms for you to use. This can be especially helpful if you have not appointed an agent in part one of your colorado advance medical directive to communicate those wishes for you. An advance directive is a written statement about your wishes regarding medical treatment. Advance healthcare directive, personal directive, personal wish statement, medical directive, lifeprolonging treatment form. It also lets you write down your wishes about donation of organs and the.
To make things a little confusing, states use various terms to describe their advance directive forms. This directive cannot be executed for minors unless a physician states the minor has a terminal or irreversible condition. If you have legal questions about this form or would like to develop a different form to meet your particular needs, you should talk with an attorney. Download this virginia advance directive form, also known as, virginia advance medical directive, in order to designate a trusted relative or friend to make medical decisions on your behalf in adobe pdf.
Advanced health care directive form california courts. This form is being provided to you as a public service. Directive to physicians and family or surrogates form this form is designed to help you communicate your wishes about medical treatment at some time in the future when you are unable to make your wishes known because of illness or injury. Other forms of advance directives for health care that substantially comply with this form may be used in georgia. In certain circumstances wherein a patient cannot communicate their decision due to being physically or mentally incapable, a health care directive form is given in advance. This document combines a health care directive, which is your living will, along with a.
I am pleased to send you an advance directive form that you can use to plan for future health care decisions. This advance directive says what i do want and what i do not want for my. Federal law requires that you be told of your right to make an advance directive when you are admitted to a health care. Youll find instructions on how to fill out the forms. In the state of michigan, the durable power of attorney for health care dpoahc form is the most widely used advance directive. If your wishes change, fill out a new health care directive form. Give copies of the advance directive to your health care agent, health care providers, family, close friends, spiritual advisors, and any other individuals who might be involved in your care.
When planning for your future medical care, prepare your advance directives to be sure your loved ones make health. The new jersey commission on legal and ethical problems in the delivery of health care page 1 of 2 proxy directive durable power of attorney for health care designation of health care. This form also allows you to express your values and beliefs with respect to health care decisions and your preferences for health care. Your advance directive will only be used when you are unable to. It is your responsibility to provide a copy of your advance directive to your treating physician. The north carolina living will, or advance directive form is designed to allow patients to legally decide upon the medical health care treatment they can receive should they become so ill that they are unable to make these choices. Sign the form with witnesses or a notary present to make it legal after you have completed your advance directive, discuss it with your healthcare team. By providing these forms and information, everplans is not providing legal advice to you. New mexico optional advance health care directive form. Advance directives washington state medical association wsma.
If i am incapable of making an informed decision regarding my health care, i direct my health care providers to follow my instructions below. This guide includes information about advance directive forms with tips on how to use them. The form provided in section 4701 may, but need not, be used to create an advance health care directive. This advance directives resource center is intended to provide consumers with information about advance directives in indiana. As long as you are able to decide and express your own decisions, your advance directives will not be used. Talk about this form with the person you have chosen to make. Sample advance directive form american family physician. This form may be used in the state of alabama to make your wishes known about what medical treatment or other care you.