Mental Health Advance Health Care Directive printable pdf download

Alaska

MENTAL HEALTH ADVANCE HEALTH

CARE DIRECTIVE

(Chapter 38 Session Laws of Alaska 2004)

EXPLANATION

This form pulls out the specific mental health care provisions (Part 4) contained in Alaska

Statutes Title 13, Chapter 52 (AS 13.52) enacted in 2004, which becomes effective on January 1,

2005 and also includes the option to designate someone to make mental health care decisions for

you (Agent) if it has been determined you are incompetent to do so. It is not required to

designate an Agent, but if you have someone you trust completely, it can be a big help in

preventing psychiatric procedures being forced upon you. The full form with the other parts

(General Health Care Directives, Anatomical Gifts, and Designation of Primary Physician) can

be found at You may complete or modify

all or any part of this form and are free to use a different form if the form complies with the

requirements of AS 13.52.

After completing this form, sign and date the form at the end and have the form notarized

or witnessed as provided below. Give a copy of the signed and completed form to your agent or

surrogate, if any, to your physician, to any other health care providers you may have, to any

health care institution at which you are receiving care, and to any health care agents you have

named. You also might want to keep a copy handy in order to show it to a mental health facility

in the event that becomes necessary. If you have named someone as your Agent you should talk

to him/her/them to make sure they understands your wishes and are willing to take the

responsibility.

You have the right to revoke this advance health care directive or replace this form at any

time, except that you may not revoke this declaration when you are determined not to be

competent by a court, by two physicians, at least one of whom shall be a psychiatrist, or by both

a physician and a professional mental health clinician. In this advance health care directive,

"competent" means that you have the capacity

(1) to assimilate relevant facts and to appreciate and understand your situation

with regard to those facts; and

(2) to participate in treatment decisions by means of a rational thought process.

DIRECTIONS REGARDING MENTAL HEALTH CARE

This part of the declaration allows you to make decisions in advance about mental health

treatment. The instructions that you include in this declaration will be followed only if a court,

two physicians that include a psychiatrist, or a physician and a professional mental health

clinician believe that you are not competent and cannot make treatment decisions. Otherwise,

you will be considered to be competent and to have the capacity to give or withhold consent for

the treatments.

If you are satisfied to allow your agent to determine what is best for you in making these

mental health decisions, you do not need to fill out this part of the form. If you do fill out this

part of the form, you may strike any wording or otherwise change it to your liking.

Mental Health Advance Health Care Directive