My Advance Care Plan Form
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2Virginia
My Advance Care Plan
“Communicating my Healthcare Wishes”
Name: _____________________________ Social Security Number: XXX – XX - ________
Address: __________________________ City: ______________ State & ZIP: __________
Phone: (______) _______ - ___________ Date of Birth: _______ - _______ - ___________
Sentara Healthcare Advance Directive
USLWR Source Code 36901001
Date: _________________ 20_____
(Cross out any section(s) you do not wish to include in your document.)
Section I
If I am unable to make decisions for myself, or unable to communicate my healthcare wishes about
treatment, I appoint the person(s) listed below to be my designated Healthcare Agent(s), who will make
my wishes known to my healthcare providers. I direct my healthcare providers and family to respect
and honor my wishes.
Primary Healthcare Agent:
Name: ___________________________________ Email: ________________________________
Address: ________________________________ City: _______________ State & ZIP: _________
Primary Phone: (_____) _______ - _________ Alt. Phone: (_____) _______ - _________
Secondary Healthcare Agent:
Name: ___________________________________ Email: ________________________________
Address: ________________________________ City: _______________ State & ZIP: _________
Primary Phone: (_____) _______ - _________ Alt. Phone: (_____) _______ - _________
My Healthcare Agent(s) shall make healthcare decisions based on my previously expressed wishes, my
personal beliefs and values and shall be granted the power to make healthcare decisions as outlined in the
Virginia Healthcare Decisions Act, 54.1-2984.
______ If I initial this line, my agent WILL have the authority to restrict visitors in a healthcare facility.
(Initials)
General Healthcare Instructions:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
rev. 07/2015
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Parent category: Medical