Fillable Ahp Advance Directive Information printable pdf download

[Patient Label Here]

AHP Advance Directive Information

Patient Name:________________________________

DOB: ___________ MRN:_______________________

Your Rights as an Arch Health Partners Patient

You have a legal right to make known your wishes about your medical care, including the right to accept or

refuse treatment. The document “Advance Health Care Directive” is a means to specify your wishes and to

make them legally binding.

What is an Advance Health Care Directive?

This is a legal document that enables you to specify your desires about life-sustaining treatment. It also allows you to

name someone you trust to speak for you when you are incapacitated. This document replaces “Living Wills” and the

“Durable Power of Attorney for Health Care”. You can identify your primary care physician and specify your wishes

about CPR, feeding tubes, breathing machines, pain medication, organ donation and other desires.

How do I find out more?

Internet Resources

The booklet “Finding Your Way” is a useful guide to thinking about and discussing these issues. To order a copy,

send $1.50 check (payable to “CHCD”) to Center for Healthcare Decisions, 3400 Data Drive, Rancho Cordova, CA

95670 or order it through their website,

How do I obtain an Advance Healthcare Directive form?

The California Medical Association-- Kit available for nominal fee (currently $6)

1201 J St STE 200

Phone (800) 786-4262

Sacramento, CA 95814

Fax: (916) 551-2036

Obtain the form on-line free of charge at:

What other kinds of directives are available?

Physician Orders for Life-Sustaining Treatment (POLST)—this complements the Advance Directive by having a

physician order signed and ready-to-go in the event you need life-sustaining treatment. Specific instructions

may be made about CPR and medical interventions like assisted breathing and artificial feeding.

Arch Health Partners has a written policy on Advance Directives. Check the box below if you wish more information.

Patients

: Please check the appropriate box(es):

⁯I have an Advance Directive and/or POLST. I will provide Arch Health Partners with a copy. [Give the copy to one

of our staff or mail to AHP, 15611 Pomerado Road, Poway, CA 92064, ATTN: Medical Records.]

⁯I have an Advance Directive/POLST but do not wish to provide AHP with a copy.

⁯I do not have an Advance Directive/POLST.

⁯I would like more information on Arch Health Partners policy on Advance Directives.

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______________________________________________

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Signature of Patient or Patient’s Legal Representative

Date

Ahp Advance Directive Information