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.

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

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;



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



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

that I have completed in the past.

______________________________

__________________________________________________________________

Date

Signature

________________________________________________

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;

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,

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;

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

8. The appointed agent or alternate agent.

_________________________________________________

Signature of Witness

Printed Name of Witness

_________________________________________________

______________________ _________ _____________

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: ______________________________________________

Page 4 of 4

Utah Advance Health Care Directive Page 4

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