Fillable Advance Directive (Page 6 of 7) in pdf

Advance Directive Page 6

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PART C: HEALTH CARE INSTRUCTIONS (CONTINUED)

7. Other Documents. A “health care power of attorney” is any document you may have signed to

appoint a representative to make health care decisions for you.

INITIAL ONE:

_______ I have previously signed a health care power of attorney. I want it to remain in

effect unless I appointed a health care representative after signing the health care

power of attorney.

_______ I have a health care power of attorney, and I REVOKE IT.

_______I DO NOT have a health care power of attorney.

_____________________________________

(Date)

SIGN HERE TO GIVE INSTRUCTIONS

_____________________________________

(Signature)

PART D: DECLARATION OF WITNESSES

We declare that the person signing this advance directive:

(a) Is personally known to us or has provided proof of identity;

(b) Signed or acknowledged that person’s signature on the advance directive in our presence;

(d) Has not appointed either of us as health care representative or alternative representative;

and

(e) Is not a patient for whom either of us is attending physician.

Witnessed By:

_______________________________________ _____________________________________

(Signature of Witness/Date)

(Printed Name of Witness)

_______________________________________ _____________________________________

(Signature of Witness/Date)

(Printed Name of Witness)

NOTE: One witness must not be a relative (by blood, marriage or adoption) of the person signing this

advance directive. That witness must also not be entitled to any portion of the person’s estate upon

death. That witness must also not own, operate or be employed at a health care facility where the

person is a patient or resident.

Advance Directive Page 6

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