Advance Directive Acknowledgment (Page 2 of 2) in pdf

Advance Directive Acknowledgment Page 2

Ar k a n s a s S u r g i c a l

H O S P I T A L

ADVANCE DIRECTIVE ACKNOWLEDGMENT

Please circle or initial:

At this time, I do / do not have an Advance Directive.

(Circle one.)

)

Would you like further information regarding Advance Directive/Living Will? _____ Yes

_____ No

(Initial correct answer.)

)

*3. Information given/Advance Directives? _____Yes

_____ No

(Initial correct answer.)

)

*4. Do you have a healthcare proxy? _____Yes

_____ No

(Initial correct answer.)

)

Please initial the following statements if they are correct.

_____ I have been given written material about my right to accept or refuse medical treatments.

_____ I have been informed of my rights to formulate Advance Directives.

_____ I understand that I am not required to have an Advance Directive in order to receive medical

treatment at this healthcare facility.

_____ I understand that the terms of any Advance Directive that I execute or have executed will be followed

by the healthcare facility and my caregivers to the extent permitted by law.

_____ I understand that my Advance Directive can be rescinded per my request anytime during my stay.

Please check one of the following statements:

[ ]

I HAVE executed an Advance Directive.

I HAVE NOT executed an Advance Directive.

[ ]

I HAVE executed a healthcare proxy.

I HAVE NOT executed a healthcare proxy.

Signed: _________________________________________________________________ Date: _________________

Witness Signature: ________________________________________________________ Date: _________________

* Copies Required

Arkansas Surgical Hospital

Advance Directive Acknowledgement

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Advance Directive Acknowledgment Page 2