Fillable Advance Health Care Directive Template (Page 2 of 6) in pdf

GENERAL INSTRUCTIONS

You should read this form carefully before filling it in. You should fill it in completely.

If there are health care decisions you do not want to make, you should strike the wording

of that decision rather than leave it blank. You may not change the qualifications for

witnesses or agents, even if you cross out the wording. You should write legibly.

After you have filled out the form completely, you should sign the form before a

notary public.

Although signing before a notary public is not legally required, it is

advisable. It is advisable because the notary, as well as your witnesses, can testify as to

your competence when you sign the directive, if your competence becomes an issue.

Notaries, who are registered with the State, are often easier to locate later than

witnesses.

You should retain your original Advance Health care Directive, and give copies to

your doctor, agent, spouse, family members, and close friends, if you desire. You should

explain to each person who receives a copy of your health care directive what choices

you made on the form, and why. This will help if, while you lack competence, there arises

a need to make a health care decision that is not explicitly set forth on your advance

health care directive form.

This form does not contain all of the types of health care decisions you are legally

entitled to make. For example, the form does not give you the opportunity to nominate a

guardian, in the event you become incompetent and need one. Also, the form does not

give you the opportunity to designate a primary care physician, or another person, to

certify that you lack the capacity to make your own decisions on health care. Finally, the

form does not include a provision that accommodates a person’s religious or moral

beliefs. If you would like to exercise these options, you should talk to an attorney. If

anything on the form conflicts with your religious beliefs, you should contact your clergy.

PART I. INSTRUCTIONS FOR HEALTH CARE DECISIONS

If you are an adult who is mentally competent, you have the right to accept or refuse

medical or surgical treatment, if such refusal is not contrary to existing public health laws. You

may give advance instructions for medical or surgical treatment that you want or do not want.

These instructions will become effective if you lose the capacity to accept or refuse medical or

surgical treatment. You may limit your instructions to take effect only if you are in a specified

medical condition. If you give an instruction that you do not want your life prolonged, that

instruction will only take effect if you are in a “qualifying condition.” A “qualifying condition” is

either a terminal condition or permanent unconsciousness.

If you want to give instructions to accept or refuse medical or surgical treatment, you

should fill in the spaces on the following page. You may cross out any wording you do not

want.

Advance Health Care Directive of ________________________________________________________

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Advance Health Care Directive Template Page 2