Idaho - Health Care Directive Registry Template

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Idaho Health Care Directive Registry
I want to:
Store a copy of my health care directive in the Registry.
Replace my health care directive now in the registry, file number __________, with a new one.
Remove my health care directive from the registry.
Request a replacement wallet card (no change to my health care directive now in the Registry)
The personal information below is provided with the understanding that it will be stored in the
Idaho Health Care Directive Registry. I certify that the Health Care Directive and Durable Power
of Attorney that accompanies this Agreement is my currently effective health care directive, and
was duly executed, witnessed and acknowledged in accordance with the laws of the State of
Idaho.
I understand that use of the health care directive registry is entirely voluntary, and no one is
required to register their living will or durable power of attorney with the Idaho Secretary of
State. Registration or non-registration of these types of documents has no effect upon their
validity. Registration only makes these documents more accessible in time of emergency.
Fill in all blanks of this Agreement and enclose your Health Care Directive with this Agreement. We
recommend that your Directive be witnessed or notarized.
Last Name
First Name
Middle Name
Address
Date of Birth
Telephone Number
City
Zip Code
State
Address to return wallet card and documents (if different from address above)
Middle Name
Last Name
First Name
Address
City
Zip Code
State
Sign and date this Agreement and mail or deliver
Signature of Registrant
it to: Idaho Secretary of State
Attn: Health Care Directive Registrar
Printed Name
700 West Jefferson, Room E205
PO Box 83720
Boise, ID 83720-0080
Date

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