Fillable Utah Advance Health Care Directive Form (Page 2 of 4) in pdf

Part I: My Agent (continued)

D. Agent’s Authority

If I cannot make decisions or speak for myself (in other words, after my physician or another authorized provider

finds that I lack health care decision making capacity under Section 75-2a-104 of the Advance Health Care

Directive Act), my agent has the power to make any health care decision I could have made such as, but not

limited to:



Consent to, refuse, or withdraw any health care. This may include care to prolong my life such as food and

fluids by tube, use of antibiotics, CPR (cardiopulmonary resuscitation), and dialysis, and mental health care,

such as convulsive therapy and psychoactive medications. This authority is subject to any limits in

paragraph F of Part I or in Part II of this directive.



Hire and fire health care providers.



Ask questions and get answers from health care providers.



Consent to admission or transfer to a health care provider or health care facility, including a mental health

facility, subject to any limits in paragraphs E or F of Part I.



Get copies of my medical records.



Ask for consultations or second opinions.

My agent cannot force health care against my will, even if a physician has found that I lack health care decision

making capacity.

E. Other Authority

My agent has the powers below only if I initial the “yes” option that precedes the statement. I authorize my agent to:

____YES ____ NO Get copies of my medical records at any time, even when I can speak for myself.

____YES ____ NO Admit me to a licensed health care facility, such as a hospital, nursing home, assisted living,

or other facility for long-term placement other than convalescent or recuperative care.

F. Limits/Expansion of Authority

I wish to limit or expand the powers of my health care agent as follows:

_____________________________________________________________________________________________________

G. Nomination of Guardian

Even though appointing an agent should help you avoid a guardianship, a guardianship may still be necessary.

Initial the "YES" option if you want the court to appoint your agent or, if your agent is unable or unwilling to

serve, your alternate agent, to serve as your guardian, if a guardianship is ever necessary.

I, being of sound mind and not acting under duress, fraud, or other undue influence, do hereby

____YES ____ NO

nominate my agent, or if my agent is unable or unwilling to serve, I hereby nominate my

alternate agent, to serve as my guardian in the event that, after the date of this instrument, I

become incapacitated.

H. Consent to Participate in Medical Research

I authorize my agent to consent to my participation in medical research or clinical trials, even

____YES ____ NO

if I may not benefit from the results.

I. Organ Donation

If I have not otherwise agreed to organ donation, my agent may consent to the donation of my

____YES ____ NO

organs for the purpose of organ transplantation.

Name: ______________________________________________

Page 2 of 4

Utah Advance Health Care Directive Form Page 2

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