Fillable Utah Advance Health Care Directive (Page 2 of 4) in pdf

Part I: My Agent (continued)

D. Agent’s Authority

D. Agent’s Authority.

D. Agent’s Authority

If I cannot make decisions or speak for myself (in other words, after my physician or another authorized provider

f I cannot make decisions or speak for myself (in other words, after my physician or another authorized provider finds that I

finds that I lack health care decision making capacity under Section 75-2a-104 of the Advance Health Care

If I cannot make decisions or speak for myself (in other words, after my physician or another authorized provider

lack health care decision making capacity under Section 75-2a-104 of the Advance Health Care Directive Act), my agent has

finds that I lack health care decision making capacity under Section 75-2a-104 of the Advance Health Care

Directive Act), my agent has the power to make any health care decision I could have made such as, but not

the power to make any health care decision I could have made such as, but not limited to:

Directive Act), my agent has the power to make any health care decision I could have made such as, but not

limited to:

• Consent to, refuse, or withdraw any health care. This

• Hire and fire health care providers.

limited to:

Consent to, refuse, or withdraw any health care. This may include care to prolong my life such as food and



may include care to prolong my life such as food and

• Ask questions and get answers from health care providers.

fluids by tube, use of antibiotics, CPR (cardiopulmonary resuscitation), and dialysis, and mental health care,

Consent to, refuse, or withdraw any health care. This may include care to prolong my life such as food and



fluids by tube, use of antibiotics, CPR (cardiopulmonary

• Consent to admission or transfer to a health care provider

such as convulsive therapy and psychoactive medications. This authority is subject to any limits in

fluids by tube, use of antibiotics, CPR (cardiopulmonary resuscitation), and dialysis, and mental health care,

resuscitation), and dialysis, and mental health care, such

or health care facility, including a mental health facility,

paragraph F of Part I or in Part II of this directive.

such as convulsive therapy and psychoactive medications. This authority is subject to any limits in

as convulsive therapy and psychoactive medications.

subject to any limits in paragraphs E or F of Part I.

paragraph F of Part I or in Part II of this directive.

This authority is subject to any limits in paragraph F

Hire and fire health care providers.



• Get copies of my medical records.

of Part I or in Part II of this directive.

Hire and fire health care providers.



Ask questions and get answers from health care providers.



• Ask for consultations or second opinions.

Ask questions and get answers from health care providers.



Consent to admission or transfer to a health care provider or health care facility, including a mental health



My agent cannot force health care against my will, even if a physician has found that I lack health care decision making capacity.

Consent to admission or transfer to a health care provider or health care facility, including a mental health

facility, subject to any limits in paragraphs E or F of Part I.



facility, subject to any limits in paragraphs E or F of Part I.

Get copies of my medical records.



E. Agent’s authority when I can speak for myself.

Get copies of my medical records.



Ask for consultations or second opinions.



Complete this section ONLY IF you want your Agent to have authority to access your health care records starting today.

Ask for consultations or second opinions.

My agent cannot force health care against my will, even if a physician has found that I lack health care decision



Otherwise, your Agent may only access your health records if you can’t speak for yourself, as explained in Section D above.

My agent cannot force health care against my will, even if a physician has found that I lack health care decision

making capacity.

My agent has the powers below ONLY IF I initial the “yes” option that precedes the statement. I authorize my agent to:

making capacity.

Medical Records

Health Care Financial Records

E. Other Authority

____ YES Access all my medical records; OR

____ YES Access all my health care financial, billing

E. Other Authority

My agent has the powers below only if I initial the “yes” option that precedes the statement. I authorize my agent to:

and payment records; OR

____ YES Access my medical records for the treatment

My agent has the powers below only if I initial the “yes” option that precedes the statement. I authorize my agent to:

____YES ____ NO Get copies of my medical records at any time, even when I can speak for myself.

dates of______________ to______________ ; and

____ YES Access my healthcare financial, billing and

____YES ____ NO Get copies of my medical records at any time, even when I can speak for myself.

payment records for the treatment dates

____YES ____ NO Admit me to a licensed health care facility, such as a hospital, nursing home, assisted living,

____ YES Access my sensitive medical information which

of______________ to______________.

____YES ____ NO Admit me to a licensed health care facility, such as a hospital, nursing home, assisted living,

or other facility for long-term placement other than convalescent or recuperative care.

includes any mental health treatment, psychological

testing, addiction treatment, treatment for HIV or

or other facility for long-term placement other than convalescent or recuperative care.

____ YES Other (please specify) ______________________

sexually transmitted diseases.

F. Limits/Expansion of Authority

__________________________________________

F. Limits/Expansion of Authority

____ YES Other (please specify) ______________________

__________________________________________.

I wish to limit or expand the powers of my health care agent as follows:

__________________________________________.

I wish to limit or expand the powers of my health care agent as follows:

_____________________________________________________________________________________________________

F. Other Authority Including Limits/Expansion of Authority.

_____________________________________________________________________________________________________

My agent has the powers and limitations below ONLY IF I initial the “yes” option that precedes the statement. I authorize

_____________________________________________________________________________________________________

my agent to:

G. Nomination of Guardian

____ YES Admit me to a licensed health care facility, such as a hospital, nursing home, assisted living, or other facility

G. Nomination of Guardian

Even though appointing an agent should help you avoid a guardianship, a guardianship may still be necessary.

for long-term placement other than convalescent or recuperative care.

Even though appointing an agent should help you avoid a guardianship, a guardianship may still be necessary.

Initial the "YES" option if you want the court to appoint your agent or, if your agent is unable or unwilling to

: ______________________________

____ YES I wish to limit or expand the powers of my health care agent as follows

serve, your alternate agent, to serve as your guardian, if a guardianship is ever necessary.

Initial the "YES" option if you want the court to appoint your agent or, if your agent is unable or unwilling to

___________________________________________________________________________________

serve, your alternate agent, to serve as your guardian, if a guardianship is ever necessary.

I, being of sound mind and not acting under duress, fraud, or other undue influence, do hereby

____YES ____ NO

G. Nomination of Guardian

nominate my agent, or if my agent is unable or unwilling to serve, I hereby nominate my

I, being of sound mind and not acting under duress, fraud, or other undue influence, do hereby

____YES ____ NO

alternate agent, to serve as my guardian in the event that, after the date of this instrument, I

nominate my agent, or if my agent is unable or unwilling to serve, I hereby nominate my

Even though appointing an agent should help you avoid a guardianship, a guardianship may still be necessary. Initial the

“YES” option if you want the court to appoint your agent or, if your agent is unable or unwilling to serve, your alternate

become incapacitated.

alternate agent, to serve as my guardian in the event that, after the date of this instrument, I

agent, to serve as your guardian, if a guardianship is ever necessary.

become incapacitated.

H. Consent to Participate in Medical Research

____ YES ____ NO I, being of sound mind and not acting under duress, fraud, or other undue influence, do hereby

H. Consent to Participate in Medical Research

nominate my agent, or if my agent is unable or unwilling to serve, I hereby nominate my alternate

I authorize my agent to consent to my participation in medical research or clinical trials, even

____YES ____ NO

agent, to serve as my guardian in the event that, after the date of this instrument, I become incapacitated.

I authorize my agent to consent to my participation in medical research or clinical trials, even

if I may not benefit from the results.

____YES ____ NO

if I may not benefit from the results.

H. Consent to Participate in Medical Research

I. Organ Donation

____ YES ____ NO I authorize my agent to consent to my participation.

I. Organ Donation

If I have not otherwise agreed to organ donation, my agent may consent to the donation of my

____YES ____ NO

If I have not otherwise agreed to organ donation, my agent may consent to the donation of my

organs for the purpose of organ transplantation.

____YES ____ NO

I. Organ Donation

organs for the purpose of organ transplantation.

____ YES ____ NO If I have not otherwise agreed to organ donation, my agent may consent to the donation of my organs

for the purpose of organ transplantation.

Name: ______________________________________________

Page 2 of 4

Name: ______________________________________________

Page 2 of 4

Utah Advance Health Care Directive Page 2

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