Advance Directives - Living Will Form printable pdf download

Stark Ambulatory Surgery Center

Canton, Ohio 44718

ADVANCE DIRECTIVES AND LIVING WILL INFORMATION

It is our policy is to ensure that all personnel and patients are aware that the Stark County Ambulatory Surgery Center does not accept or

honor any advance directives and/or living wills. However, the patient must provide this information on the day of the procedure in the

event that the patient is transferred to a different acute care facility(hospital).

This form needs to be completed and brought to the office on the day of your procedure.

_________ I have a living will, but should the need arise for resuscitation of my lungs or heart during my stay here at the Stark

Ambulatory Surgery Center, I hereby allow the nurses and the physicians to perform resuscitation measures and transport me to an acute

care setting (hospital)as soon as possible.

_________ I do not have a living will.

Patient Signature:__________________________Date:____________________

Witness:_________________________________ Date:____________________

If you do not have such a document information can be requested at the time of your procedure or information can be found at the

following website:

PATIENT APPOINTMENT OF REPRESENTATIVE

I hereby appoint the person listed below to be my representative. I authorize you to use and disclose my private healthcare

information (PHI) to this representative. I have the right to rescind this appointment at anytime with written notice to the Stark

Ambulatory Surgery Center. (SASC)

This person may receive my PHI and discuss this information in my treatment and/or payment.

Name of Representative:__________________________________________________

Birth Date of Representative: Month:___________

Day:_____________

Relationship to Patient:__________________________________

Does This Person have Medical Power of Attorney? _______________

Time frame of Appointment: From this day forward with no restrictions:________________

Date to/from:________________________________________

Name of Patient:___________________________________________________________

Signature of Patient:________________________________________________________

Date:_____________________

Advance Directives - Living Will Form