Advance Healthcare Directive & Living Will

State of    |  County of  

Part I — Declaration of Principal

I,  , residing at:

Address:  
City:     State:     ZIP:  
Date of Birth:   /   /       

being of sound mind and not acting under duress, fraud, or undue influence, hereby make this Advance Healthcare Directive. This document expresses my wishes regarding healthcare decisions in the event I am unable to make or communicate those decisions myself.

This directive shall become effective upon my incapacity as determined by one or more licensed physicians, or as otherwise required by the laws of the state named above.

Part II — Appointment of Healthcare Agent
(Durable Power of Attorney for Healthcare)

A. Primary Healthcare Agent

Name:  
Relationship:  
Address:  
Phone (Primary):     Phone (Alt):  
Email:  

B. Alternate Healthcare Agent (if Primary is unavailable or unwilling)

Name:  
Relationship:  
Address:  
Phone (Primary):     Phone (Alt):  
Email:  

C. Powers Granted to Healthcare Agent

I grant my Healthcare Agent the authority to make healthcare decisions on my behalf, including but not limited to:

• Consenting to or refusing any medical treatment, procedure, surgery, or diagnostic test
• Accessing my medical records and information under HIPAA (45 C.F.R. §§ 164.502(a)(1)(vi), 164.510(b))
• Authorizing admission to or discharge from any medical facility, hospice, or care program
• Hiring and dismissing healthcare providers
• Making decisions about anatomical gifts, autopsy, and disposition of remains
• Taking any other action I could take if I were able to make healthcare decisions

D. Limitations on Agent's Authority

The following limitations apply to my Healthcare Agent's authority (check all that apply or write "NONE"):

Part III — Life-Sustaining Treatment Directives

The following instructions apply if I have a terminal condition, am in a persistent vegetative state, or have an end-stage condition from which there is no reasonable medical expectation of recovery.

A. General Directive

Check ONE of the following:

B. Specific Treatment Directives

For each treatment below, indicate your wish by checking the appropriate column:

C. Special Circumstances

Pregnancy: If I am pregnant and my life-sustaining treatment wishes conflict with the continuation of the pregnancy, I direct that:

Dementia / Cognitive Decline: If I am diagnosed with severe and irreversible dementia and no longer recognize family members or myself, I direct that:

Part IV — Pain Management & Comfort Care

Regardless of any other directive in this document, I direct that:

• I receive adequate pain relief and comfort measures at all times.
• I   DO /   DO NOT wish to receive palliative sedation if my pain cannot otherwise be controlled.
• I wish to die at:   Home     Hospice Facility     Hospital     No Preference

Additional comfort care instructions:

Part V — Organ and Tissue Donation

Upon my death, I direct that:

Part VI — Mental Health Directives (Psychiatric Advance Directive)

In the event I am unable to make mental health decisions due to a psychiatric crisis or cognitive incapacity:

Preferred Treatment Facility (if applicable):  

Medications I have previously responded well to:  

Medications I refuse (list and reason):  

Other mental health instructions:

Part VII — Personal Values & Wishes

The following statements reflect my personal values and should guide my Healthcare Agent and providers in interpreting this document:

Religious / Spiritual Beliefs:

Quality of Life Considerations (what conditions would make life not worth living for me):

Other Instructions or Wishes:

Part VIII — HIPAA Authorization

I authorize all healthcare providers, hospitals, insurance companies, and other covered entities to release my medical records and health information to my Healthcare Agent named in Part II of this document. This authorization is made pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. § 164.508, and shall remain in effect until revoked in writing.

Part IX — Revocation

I understand I may revoke this Advance Healthcare Directive at any time while I am competent by:

• Destroying this document and all copies
• Signing and dating a written statement of revocation
• Orally stating my intent to revoke before at least two witnesses
• Executing a new, later-dated Advance Directive

Part X — Signature of Principal

I, the undersigned, declare that this document reflects my wishes and that I am of legal age (18 or older, or as required by state law), of sound mind, and acting voluntarily and free from undue influence.

Part XI — Witness Statements

This document must be signed by two witnesses. Witness requirements vary by state. Generally, witnesses may NOT be: the Healthcare Agent named above; a relative by blood, marriage, or adoption; a beneficiary of the Principal's estate; the Principal's physician or any employee of the Principal's healthcare provider; or anyone financially responsible for the Principal's care. Check your state's laws for specific requirements.

Witness 1

I declare that I am at least 18 years old, that the Principal signed or acknowledged this document in my presence, that the Principal appears to be of sound mind and free of duress, and that I am not disqualified from serving as a witness under applicable state law.

Witness 2

I declare that I am at least 18 years old, that the Principal signed or acknowledged this document in my presence, that the Principal appears to be of sound mind and free of duress, and that I am not disqualified from serving as a witness under applicable state law.

Part XII — Notarization

Many states require notarization of an Advance Healthcare Directive. Even where not required, notarization is recommended to strengthen the document's legal validity. Check your state's requirements.

Part XIII — Healthcare Agent Acceptance

I,  , accept the appointment as Healthcare Agent for  . I understand and accept the responsibilities of this role and agree to act in accordance with the wishes expressed in this document and in the best interest of the Principal.

Part XIV — Distribution & Storage

I have provided copies of this document to (check all that apply):