Utah Advance Health Care Directive Form printable pdf download

Utah Advance Health Care Directive

(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

cannot make decisions or speak for yourself.

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 IV: Makes your directive legal.

My Personal Information

Name: ______________________________________________________________________________

Street Address: _______________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Telephone: (_______) _____________________ Cell Phone: (_______) _____________________

Birth Date: ____________________________

Part I: My Agent

(Health Care Power of Attorney)

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

or C below. No one can force you to name an agent.

I do not want to choose an agent.

B. My Agent

Agent’s Name: _______________________________________________________________________

Street Address: _______________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________

Work Phone: (_______) _____________________

C. My Alternate Agent

This person will serve as your agent if your agent, named above, is unable or unwilling to serve.

Alternate Agent’s Name: _______________________________________________________________

Street Address: _______________________________________________________________________

City, State, Zip Code: _________________________________________________________________

Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________

Work Phone: (_______) _____________________

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Utah Advance Health Care Directive Form