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

Part II: My Health Care Wishes (continued)

Additional instructions about your health care wishes:

________________________________________________________________________________________________________

If you do not want emergency medical service providers to provide CPR or other life sustaining measures, you must work with a

physician or APRN to complete an order that reflects your wishes on a form approved by the Utah Department of Health.

If you do not want emergency medical service providers to provide CPR or other life sustaining measures, you must work with a

physician or APRN to complete an order that reflects your wishes on a form approved by the Utah Department of Health.

Part III: Revoking or Changing a Directive

I may revoke or change this directive by:

Writing “void” across the form, burning, tearing, or otherwise destroying or defacing this document or directing another



Writing “void” across the form, burning, tearing, or otherwise destroying or defacing this document or directing another



person to do the same on my behalf;

Writing “void” across the form, burning, tearing, or otherwise destroying or defacing this document or directing another



person to do the same on my behalf;

Signing a written revocation of the directive, or directing another person to sign a revocation on my behalf;



Signing a written revocation of the directive, or directing another person to sign a revocation on my behalf;



Signing a written revocation of the directive, or directing another person to sign a revocation on my behalf;

Stating that I wish to revoke the directive in the presence of a witness who: is 18 years of age or older; will not be



Stating that I wish to revoke the directive in the presence of a witness who: is 18 years of age or older; will not be



appointed as my agent in a substitute directive; will not become a default surrogate if the directive is revoked; and signs

Stating that I wish to revoke the directive in the presence of a witness who: is 18 years of age or older; will not be



appointed as my agent in a substitute directive; will not become a default surrogate if the directive is revoked; and signs

and dates a written document confirming my statement; or

appointed as my agent in a substitute directive; will not become a default surrogate if the directive is revoked; and signs

and dates a written document confirming my statement; or

Signing a new directive. (If you sign more than one Advance Health Care Directive, the most recent one applies.)



Signing a new directive. (If you sign more than one Advance Health Care Directive, the most recent one applies.)



Signing a new directive. (If you sign more than one Advance Health Care Directive, the most recent one applies.)



Part IV: Making My Directive Legal

I sign this directive voluntarily. I understand the choices I have made and declare that I am emotionally and mentally competent

to make this directive. My signature on this form revokes any living will or power of attorney form naming a health care agent

I sign this directive voluntarily. I understand the choices I have made and declare that I am emotionally and mentally competent

to make this directive. My signature on this form revokes any living will or power of attorney form naming a health care agent

that I have completed in the past.

to make this directive. My signature on this form revokes any living will or power of attorney form naming a health care agent

that I have completed in the past.

______________________________

__________________________________________________________________

______________________________

__________________________________________________________________

Date

Signature

______________________________

__________________________________________________________________

Date

Signature

Date

Signature

________________________________________________

City, County, and State of Residence

________________________________________________

City, County, and State of Residence

I have witnessed the signing of this directive, I am 18 years of age or older, and I am not:

1. Related to the declarant by blood or marriage;

I have witnessed the signing of this directive, I am 18 years of age or older, and I am not:

1. Related to the declarant by blood or marriage;

2. Entitled to any portion of the declarant's estate according to the laws of intestate succession of any state or jurisdiction or

1. Related to the declarant by blood or marriage;

2. Entitled to any portion of the declarant's estate according to the laws of intestate succession of any state or jurisdiction or

under any will or codicil of the declarant,

2. Entitled to any portion of the declarant's estate according to the laws of intestate succession of any state or jurisdiction or

under any will or codicil of the declarant,

3. A beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transfer or death deed that is held,

under any will or codicil of the declarant,

3. A beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transfer or death deed that is held,

owned, made, or established by, or on behalf of, the declarant;

3. A beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transfer or death deed that is held,

owned, made, or established by, or on behalf of, the declarant;

4. Entitled to benefit financially upon the death of the declarant;

owned, made, or established by, or on behalf of, the declarant;

4. Entitled to benefit financially upon the death of the declarant;

5. Entitled to a right to, or interest in, real or personal property upon the death of the declarant;

4. Entitled to benefit financially upon the death of the declarant;

5. Entitled to a right to, or interest in, real or personal property upon the death of the declarant;

6. Directly financially responsible for the declarant's medical care;

5. Entitled to a right to, or interest in, real or personal property upon the death of the declarant;

6. Directly financially responsible for the declarant's medical care;

7. A health care provider who is providing care to the declarant or an administrator at a health care facility in which the

6. Directly financially responsible for the declarant's medical care;

7. A health care provider who is providing care to the declarant or an administrator at a health care facility in which the

declarant is receiving care; or

7. A health care provider who is providing care to the declarant or an administrator at a health care facility in which the

declarant is receiving care; or

8. The appointed agent or alternate agent.

declarant is receiving care; or

8. The appointed agent or alternate agent.

_________________________________________________

Signature of Witness

Printed Name of Witness

_________________________________________________

Signature of Witness

Printed Name of Witness

Signature of Witness

Printed Name of Witness

_________________________________________________

______________________ _________ _____________

_________________________________________________

______________________ _________ _____________

Street Address

City

State

Zip

_________________________________________________

______________________ _________ _____________

Street Address

City

State

Zip

Street Address

City

State

Zip

If the witness is signing to confirm an oral directive, describe below the circumstances under which the directive was made.

________________________________________________________________________________________________________

Name: ______________________________________________

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Name: ______________________________________________

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Name: ______________________________________________

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Utah Advance Health Care Directive Page 4

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