Utah Advance Health Care Directive

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Utah Advance Health Care Directive
Utah Advance Health Care Directive
Utah Advance Health Care Directive
*
(Pursuant to Utah Code Section 75-2a-117, effective 2009 )
*
(Pursuant to Utah Code Section 75-2a-117, effective 2009 )
*
(Pursuant to Utah Code Section 75-2a-117, effective 2009 )
Part I:
Allows you to name another person to make health care decisions for you when you
Part I:
Allows you to name another person to make health care decisions for you when you
cannot make decisions or speak for yourself.
Part I:
Allows you to name another person to make health care decisions for you when you
cannot make decisions or speak for yourself.
cannot make decisions or speak for yourself.
Part II:
Allows you to record your wishes about health care in writing.
Part II:
Allows you to record your wishes about health care in writing.
Part II:
Allows you to record your wishes about health care in writing.
Part III: Tells you how to revoke or change this directive.
Part III: Tells you how to revoke or change this directive.
Part III: Tells you how to revoke or change this directive.
Part IV: Makes your directive legal.
Part IV: Makes your directive legal.
Part IV: Makes your directive legal.
My Personal Information
My Personal Information
My Personal Information
Name: ______________________________________________________________________________
Name: ______________________________________________________________________________
Name: ______________________________________________________________________________
Street Address: _______________________________________________________________________
Street Address: _______________________________________________________________________
Street Address: _______________________________________________________________________
City, State, Zip Code: _________________________________________________________________
City, State, Zip Code: _________________________________________________________________
City, State, Zip Code: _________________________________________________________________
Telephone: (_______) _____________________ Cell Phone: (_______) _____________________
Telephone: (_______) _____________________ Cell Phone: (_______) _____________________
Telephone: (_______) _____________________ Cell Phone: (_______) _____________________
Birth Date: ____________________________
Birth Date: ____________________________
Birth Date: ____________________________
Part I: My Agent
(Health Care Power of Attorney)
Part I: My Agent
(Health Care Power of Attorney)
Part I: My Agent
(Health Care Power of Attorney)
A. No Agent
A. No Agent
A. No Agent
If you do not want to name an agent, initial the box below, then go to Part II; do not name an agent in B
If you do not want to name an agent, initial the box below, then go to Part II; do not name an agent in B
or C below. No one can force you to name an agent.
If you do not want to name an agent, initial the box below, then go to Part II; do not name an agent in B
or C below. No one can force you to name an agent.
or C below. No one can force you to name an agent.
I do not want to choose an agent.
I do not want to choose an agent.
I do not want to choose an agent.
B. My Agent
B. My Agent
B. My Agent
Agent’s Name: _______________________________________________________________________
Agent’s Name: _______________________________________________________________________
Agent’s Name: _______________________________________________________________________
Street Address: _______________________________________________________________________
Street Address: _______________________________________________________________________
Street Address: _______________________________________________________________________
City, State, Zip Code: _________________________________________________________________
City, State, Zip Code: _________________________________________________________________
City, State, Zip Code: _________________________________________________________________
Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________
Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________
Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________
Work Phone: (_______) _____________________
Work Phone: (_______) _____________________
Work Phone: (_______) _____________________
C. My Alternate Agent
C. My Alternate Agent
C. My Alternate Agent
This person will serve as your agent if your agent, named above, is unable or unwilling to serve.
This person will serve as your agent if your agent, named above, is unable or unwilling to serve.
This person will serve as your agent if your agent, named above, is unable or unwilling to serve.
Alternate Agent’s Name: _______________________________________________________________
Alternate Agent’s Name: _______________________________________________________________
Alternate Agent’s Name: _______________________________________________________________
Street Address: _______________________________________________________________________
Street Address: _______________________________________________________________________
Street Address: _______________________________________________________________________
City, State, Zip Code: _________________________________________________________________
City, State, Zip Code: _________________________________________________________________
City, State, Zip Code: _________________________________________________________________
Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________
Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________
Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________
Work Phone: (_______) _____________________
Work Phone: (_______) _____________________
Work Phone: (_______) _____________________
*50000*
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