» Advance Directive Forms

Advance Directive Forms

Create a high quality document online now!

An advance directive allows an individual to set forth end-of-life treatment options and to choose someone else to make medical decisions on their behalf. It combines a living will and power of attorney to make it easier for hospitals and patients. A patient completes the power of attorney portion selecting an agent to represent their best interests in the chance the patient cannot themselves. Followed by the living will that allows a patient to choose if they would prefer their life prolonged even if there is no chance for a cure.

Table of Contents

By State

What is an Advance Directive?

An advance directive is a document that allows a patient to not only choose someone to make health care decisions on their behalf but also to outline their end-of-life treatment options. It replaces what used to be 2 separate documents; medical power of attorney and a living will. Both forms have been combined to create an advance directive to create an easier process for patients and medical staff.

What if the Principal is Incapacitated?

If the principal (the patient) is incapacitated then the family will be required to obtain guardianship rights from the local court. In most circumstances, a hospital will allow the spouse or family member to act as the agent by default although this depends on local and State laws.

Advance Directive vs Other Forms

Form Health Care Agent Decide Treatments Prohibit CPR
Advance Directive
Medical Power of Attorney
Living Will
Do Not Resuscitate (DNR)

How to Get an Advance Directive

The following is required to make an advance directive:

  • A competent person (the “principal”);
  • An agent willing to act (the “agent” or “health care proxy”);
  • An advance directive; and
  • A notary and/or two (2) witnesses for the signature of the principal.

Step 1 – Select an Agent

This is often referred to as the medical power of attorney portion that requires the principal to select an agent to represent their health care decisions. The agent may ONLY act if the principal cannot make decisions for themselves due to being incapacitated. The agent should understand the wishes of the principal and always keep their best interests in mind when making decisions.

  • 2nd Agent – The principal is able to select a 2nd agent to help in case the original agent is not able to perform. Although, decision-making powers cannot be shared.

Step 2 – Decide the Powers

The principal will have to decide how much power to give the agent.

This mainly consists of:

  • Electing to have the powers begin immediately or upon the principal’s incapacitation;
  • Deciding to prolong the principal’s life as long as possible (even if there is no possible cure); and
  • Selecting any post-death responsibilities (ordering an autopsy, where the remains are kept, etc.).

Any other powers should be mentioned to the agent verbally.

Step 3 – Choose End-of-Life Options

This is for the living will portion that allows the principal to select their plans if they should become in a vegetative state or uncurable situation. Under such an event, the principal can choose to stop any life support assistance such as halting breathing machines, food, or water intravenously (through an IV).

Do Not Resuscitate (DNR) – Used to inform medical personnel to not perform CPR or other life-saving procedures should an individual’s heart stop or if they are not breathing.

Step 4 – Sign

Depending on the signing laws in your State, an advance directive must be signed with a notary public, two (2) witnesses, or both. If given the choice, it’s recommended to have the document notarized.

A notary can be found online (Notarize.com), at a local bank, or using a notary service.

Step 5 – Register

It’s best to store an advance directive in an easily accessible place in the event of an emergency. It’s common to record it with a State Registry or a National Organization. Wherever the advance directive is stored, the location should be recorded in a wallet card and kept on the principal at all times.

Signing Requirements

The signing requirements are administered by the State the principal resides. After signing, the form may be used immediately.

STATE FORM NAME(S) SIGNING  LAWS
 Alabama Advance Directive for Health Care Two (2) witnesses § 22-8A-4
 Alaska Advance Health Care Directive Two (2) witnesses or a notary public AS 13.52
 Arizona Health Care Power of Attorney, Living Will One (1) witness or a notary public § 36-3224, § 36-3262
 Arkansas Durable Power of Attorney for Health Care, Declaration of Living Will Two (2) witnesses or a notary public § 20-6-103, § 20-17-202
 California Advance Health Care Directive Two (2) witnesses or a notary public PROB § 4701
 Colorado Medical Durable Power of Attorney, Declaration as to Medical or Surgical Treatment Two (2) witnesses § 15-14-506, § 15-18-104
 Connecticut Appointment of Health Care Representative, Declaration to Remove Life Support System Two (2) witnesses § 19a-575a, § 19a-575
 Delaware Advance Health Care Directive Two (2) witnesses § 2503(b)
 Florida Designation of Health Care Surrogate, Living Will Two (2) witnesses § 765.202(1), § 765.302(1)
 Georgia Advance Directive for Health Care Two (2) witnesses § 31-32-5(c)(1)
 Hawaii Advance Health Care Directive Form Two (2) witnesses or a notary public § 327E-3(b)
 Idaho Living Will and Durable Power of Attorney for Health Care Principal only § 39-4510
 Illinois Living Will Declaration, Durable Power of Attorney for Health Care  Two (2) witnesses 755 ILCS 35/3(b)
 Indiana Living Will Declaration, Health Care Representative Appointment Two (2) witnesses § 16-36-4-11
 Iowa Declaration Relating to Use of Life-Sustaining Procedures, Durable Power of Attorney for Health Care Decisions Two (2) witnesses and a notary public § 144B.3(b)
 Kansas Living Will Declaration, Durable Power of Attorney for Healthcare Decisions Two (2) witnesses and a notary public § 58-632§ 65-28,103
 Kentucky Advance Directive Two (2) witnesses or a notary public § 311.625(2)
 Louisiana Living Will Declaration, Medical Power of Attorney Two (2) witnesses RS 28:224RS 40:1151.4
 Maine Health Care Advance Directive Form Two (2) witnesses § 5-803(2)
 Maryland Advance Directive Two (2) witnesses § 5-602(c)
 Massachusetts Health Care Proxy, Living Will Directive Two (2) witnesses § 201D-2
 Michigan Durable Power of Attorney for Health Care, Living Will Two (2) witnesses or a notary public § 700.5501(b)
 Minnesota Health Care Directive Two (2) witnesses or a notary public § 145C.03
 Mississippi Advance Health Care Directive Two (2) witnesses or a notary public § 41-41-209
 Missouri Health Care Directive, Durable Power of Attorney for Health Care Two (2) witnesses and a notary public § 459.015, § 404.835
 Montana Living Will Declaration, Durable Power of Attorney for Health Care Two (2) witnesses and a notary public § 53-21-1304(2)(d)
 Nebraska Living Will Declaration, Power of Attorney for Health Care Two (2) witnesses or a notary public § 30-3404, § 20-404
 Nevada Declaration/Living Will, Durable Power of Attorney for Healthcare Decisions Two (2) witnesses  NRS 162A.790NRS 449A.439
 New Hampshire Advance Directive Two (2) witnesses or a notary public § 137-J:14
 New Jersey Medical Power of Attorney (proxy), Living Will Declaration Two (2) witnesses § 26:2H-56
 New Mexico Advance Directive for New Mexico Principal only § 24-7A-2(B)
 New York Health Care Proxy, Living Will Two (2) witnesses PBH § 2981
 North Carolina Health Care Power of Attorney, Advance Directive for a Natural Death (“Living Will”) Two (2) witnesses and a notary public § 90-321
 North Dakota Health Care Directive Two (2) witnesses or a notary public § 23-06.5-05
 Ohio Living Will Declaration, Health Care Power of Attorney Two (2) witnesses or a notary public § 2133.02(A)(1)
 Oklahoma Advance Directive for Health Care Two (2) witnesses § 63-3101.4
 Oregon Advance Directive for Health Care Two (2) witnesses or a notary public ORS 127.515(2)(b)
 Pennsylvania Durable Health Care Power of Attorney, Living Will Two (2) witnesses § 5442
 Rhode Island Living Will Declaration, Durable Power of Attorney for Healthcare Two (2) witnesses § 23-4.11-3§ 23-4.10-2
 South Carolina Health Care Power of Attorney, Living Will Declaration Two (2) witnesses and a notary public § 62-5-50444-77-40
 South Dakota Durable Power of Attorney for Health Care, Living Will Declaration Two (2) witnesses and a notary public § 59-7-2.1§ 34-12D-2
 Tennessee Advance Directive for Health Care Two (2) witnesses or a notary public § 68-11-1803(b)
 Texas Directive to Physicians and Family (living will), Durable Power of Attorney for Health Care Two (2) witnesses or a notary public § 166.154, § 166.003
 Utah Advance Health Care Directive One (1) witness § 75-2a-107(c)
 Vermont Advance Directive for Health Care Two (2) witnesses 18 V.S.A. § 9703
 Virginia Advance Medical Directive Two (2) witnesses § 54.1-2983
 Washington Durable Power of Attorney for Health Care, Health Care Directive Two (2) witnesses or a notary public RCW 11.125.050RCW 70.122.030
West Virginia Medical Power of Attorney, Living Will Two (2) witnesses and a notary public § 16-30-4
 Wisconsin Declaration to Physicians Living Will, Power of Attorney for Health Care Two (2) witnesses § 244.05§ 154.03(1)
 Wyoming Advance Health Care Directive Two (2) witnesses and a notary public § 35-22-403(b)

Where to Register

An advance directive may be registered in either the principal’s State of residence or in a national registry (see below).

State Registries (not every State has a registry)

National Registries

Sample

Download: Adobe PDF, MS Word, OpenDocument

How to Write

Download: Adobe PDF, MS Word, OpenDocument

Step 1 – Access Then Save The Advance Directive Template

The Advance Directive Template discussed on this page can be viewed using the feature image and downloaded utilizing the “PDF,” “Word,” and “ODT” button presented along with it. If you prefer to work with links, locate the three links in this section (“Adobe PDF,” “MS Word,” and “OpenDocument”), select the file version you want to work with, then save it to a folder in your system.

Step 2 – Indicate If A Medical Power Of Attorney Is Included

This packet combines two distinct directives which are both considered optional. That is, while one of these documents must be executed by the concerned Principal, he or she retains the option to determine which one or if both directives should be executed. Therefore, the first task set by the “Part I. Medical Power Of Attorney” is to solidify if it will be formally completed and executed by the Principal. Locate the checkbox statements just below the first statement (“I Choose To”) underneath this part’s title. If the Principal wishes to issue a “Medical Power Of Attorney” then the checkbox corresponding to the statement “Have A Medical Power Of Attorney” must be selected with a checkmark or an “X.”  If “Part I. Medical Power Of Attorney” will not be issued, then the checkbox corresponding to “Not Have A Medical Power Of Attorney…” must be selected. This checkbox will inform future reviewers that the first part of this document has been left unattended intentionally.  

 

Step 3 – Introduce The Principal Issuing The Medical Powers

Once it has been indicated that the first part of this packet will be issued to grant a Principal’s Health Care Agent with medical decision-making authority, the Principal and the Health Care Agent will need to be identified. This will be handled through two separate articles. Locate Article “A. Principal.” The blank line preceding the words “…With A Mailing Address Of” must be populated with the full name of the person who is executing this document as the Principal. This Party, when unconscious or incapacitated, will grant medical representational powers to the Health Care Agent that will be discussed in the next article.  Before naming the Health Care Agent, we must further discuss the Principal’s identity. His or her address will act as an excellent means of identification since it will present on items such as the Principal’s government issued I.D. or insurance paperwork. The Principal’s building number, street name or number, and suite should be produced on the next available line in Article “A. Principal.” This address should be continued by recording the name of the city where it is in the space following the term “City Of.”  The final two spaces in Article “A. Principal” expect the completion of the Principal’s address distributed as the “State Of” his or her residence followed by the appropriate “Zip Code.”

 

Step 4 – Identify The Principal-Designated Health Care Agent

The next article in this document, titled “B. Agent,” will seek to properly designate the Health Care Agent the Principal wishes to act as his or her medical representative. Place the name of the determined Health Care Agent on the first blank line that follows the bold label “B. Agent.” 

Continue through this statement to record the first line of the Health Care Agent’s residential address by furnishing its building number, street or road name/number, and suite number on the space between the words “…With A Mailing Address Of” and the term “…City Of.” Once this has been reported, dispense the “City Of” the Health Care Agent’s residential address to the next space in this statement.  Next, enter the name of the state where the Health Care Agent’s address is located along with the “Zip Code” assigned to this address across the last two available spaces of this statement.  In addition to the Health Care Agent’s name and address, his or her phone number must be included with the above information. This will enable the Reviewer of this paperwork (i.e. a Doctor tending to the Principal) to reliably contact the Health Care Agent. Therefore, supply the Health Care Agent’s cell phone number using the formatted lines attached to the label “Agent’s Telephone (Cell).” 

 

Step 5 – Name The Alternate Agent In Reserve

There may be scenarios where the Health Care Agent named above is unavailable, unreachable, or no longer has the authority to represent the Principal behind this designation. If so, the third article, labeled “C. Alternate Agent,” allows the Principal to reserve an additional Party to step into this role by automatically transferring the same principal powers designated to the Health Care Age above to the “Alternate Health Care Agent.” It should be mentioned that while the Health Care Agent retains the ability to represent the Principal and is available to do so no such automatic delegation of principal authority will occur. This article is set as a precaution to make sure the Principal enjoys continuous representation as provided by the Party named as the Health Care Agent. To name a Party as an Alternate Health Care Agent, locate the blank line following the wording “…In A Timely Manner, I select” then document the full name of the Alternate Health Care Agent to supplement this statement.  As with the Principal and the Health Care Agent, it will be important that some additional discussion regarding the identity of this Party is furnished. Thus, fill in the second and third blank spaces in this statement with the Alternate Health Care Agent’s residential address making sure across the two lines on either side of the phrase “City Of”  The final blank line in this statement seeks the name of the Alternate Health Care Agent’s state.  Finally, record the cell phone number maintained by the Alternate Health Care Agent to the area labeled “Alternate Agent’s Telephone (Cell)”  

 

Step 6 – Specify If The Principal Will Issue A Living Will

The second document of this packet enables the Principal to put his or her medical treatment preferences in writing. The topics of this directive will focus on decisions that must be made when the Principal is unable to communicate, unable to maintain consciousness, and/or suffering a traumatic medical condition or event that will lead to death. Regardless of whether the Principal will issue a living will or not, the first part of “Part II. Living Will” must be tended with information. The two checkboxes presented at the start of this part of the document will establish if the Principal has determined that he or she wishes to document a living will or if the Principal has decided to refrain from this execution. If “Part II. Living Will” shall be executed by the Principal as a representation of his or her medical treatment preferences then mark the checkbox labeled “Have A Living Will.” If the Principal has decided to “Not Have A Living Will…” then mark the second checkbox presented at the start of “Part II. Living Will.”  

 

Step 7 – Furnish The Principal Behind The Living Will Being Issued

The first area of the living will is labeled “A. Principal” and carries the task of identifying the individual intent on documenting his or her medical treatment preferences. The first available space in “A. Principal” of “Part II. Living will” requires the full name of the Principal documented for display.  Submit a production of the Principal’s mailing address with a record of the building number, street, and apartment/suite number to the second available space of this paragraph then continue with the appropriate “City Of” this address on the third space provided.  In addition to the basic mailing address, the “County Of” this address along with the “State Of” the Principal’s mailing address are required on the next two lines.   To solidify the Principal’s identity, supply the last four digits of his or her “Social Security Number (SSN)” to the empty line displayed after the placeholders “XXX-XX-” 

 

Step 8 – Establish The Principal’s Preferred Quality Of Life

The next area in “Part II. Living Will” shall address end-of-life events that leave the Principal’s body unable to function. It is strongly recommended that the Principal read the introduction to this section as it provides language that shall be considered a direct statement from the Principal.  The Principal may wish attending Medical Personnel to be kept informed of his or her stance on certain issues if he or she becomes permanently unconscious, unresponsive, or unable to communicate and has been diagnosed with a condition that will severely limit or restrict the quality of life he or she wishes maintained. Before such treatment decisions are set to paper, the definition of an “Unacceptable Quality Of Life” must be solidified. This task shall be taken care of with the Principal’s direct participation with a list in “B. Life Support.” If the Principal has determined that “An Unacceptable Quality Of Life Means…” that he or she is in a “Chronic Coma Or Persistent Vegetative State” then the first blank line in this section must be initialed by the Principal and the corresponding checkbox selected. This action will inform attending Physicians that the Principal considers being in a coma with little to no chance of recovery an intolerable state.   If the Principal requires the ability to independently communicate his or her needs mandatory to maintaining an acceptable quality of life, then the Principal must initial the blank line corresponding to the statement “No Longer Able To Communicate…” and select the checkbox that follows.  If the Principal is “No Longer Able To Recognize Family Or Friends” and believes that this will have a powerfully detrimental effect on life, then the third statement must be initialed and checked.  The Principal should initial the fourth blank line of this section and select the checkbox preceding the words “Total Dependence…” if he or she believes that a reasonable quality of life cannot be maintained when there is a “Total Dependence On Others For Daily Care.”  While this list covers a wider range of scenarios, the Principal may have additional concerns. If there is some “Other” scenario in which the Principal believes his or her living will should be applied, then he or she must initial the final statement and select its checkbox. Additionally, a description of a medical condition’s effect on the Principal that he or she finds intolerable must be dispensed to a blank line after the word “Other.”  

 

Step 9 – Address The Subject Of Artificial Nutrition And Hydration

The second area of the of “B. Life Support” requires that the Principal indicate if he or she will accept artificial nutrients, food, and hydration when suffering from a condition that causes an intolerable quality of life. Locate the instructional statement “Initial And Check One (1) Only.” If the Principal wishes that attending Health Care or Medical Personnel maintain his or her nutrient and fluid level through artificial means while suffering one of the conditions that have been initialed and checked above then the statement beginning with the words “Even If I Have The…” must be selected.  If the Principal is subjected to one of the conditions defined in the previous section as an unacceptable quality of life and does not wish to authorize being “…Treated With Food And Water By Tube OR Intravenously (IV)” then the second option in this area must be initialed by the Principal and its corresponding checkbox selected. 

 

Step 10 – Discuss The Concerned Treatment Preferences

In “C. Certain Life-Sustaining Treatment” the Principal will have the opportunity to refuse receiving life-sustaining treatment he or she is against even when there is a chance for recovery. Thus, if the Principal intends to refuse the administration of CPR or cardiopulmonary resuscitation when his or her heart or lungs have stopped functioning then the blank line labeled “Cardiopulmonary Resuscitation (CPR)” must be initialed by the Principal and the checkbox adjacent to it marked. If the Principal refuses the use of artificial “Ventilation (Breathing Machine)” then the second item of this list must be initialed and checked by the Principal.  By initialing the third blank line of this list and selecting the corresponding checkbox the Principal will automatically refuse a “Feeding Tube” used to maintain his or her nutrition and fluids. If the Principal does not wish to receive “Dialysis” should his or her kidneys fail, then the Principal must initial the fourth blank line as well as mark or check the box attached to it.  The Principal can name specific treatment that he or she intends to refuse if attempted by recording these such treatments on the blank line after the word “Other.” This option also requires that the Principal initial his or her own directive and select the checkbox placed for this item.  

 

Step 11 – Present All Principal End Of Life Wishes

Section “D. End Of Life Wishes” contains several blank lines where the Principal can declare his or her priorities when near death. Such directives may include religious concerns, funeral or memorial arrangements, and hospice care. If such directives should be included with the living will being issued, then use these available lines to present them. If more room is needed, more lines may be inserted, or you may cite an attachment that is both properly labeled and dated.   

 

Step 12 – Document The Directive’s Formal Issue Date

Now that the information above has been completed the Principal will need to sign it properly so that it can become effective. This signature must be dated as a means of verifying when this document becomes active. The date for the Principal’s signature should be provided across the three empty lines following the language “I Have Signed This…” This date should be produced as a two-digit calendar day, the full name of the month, then the two-digit calendar years. Notice these lines have been formatted to dispense this date appropriately.

 

Step 13 – Prove The Principal’s Intention For This Directive

Once the Principal has recorded his or her signature date, he or she must sign the “Principal’s Signature” line (on that day). this line can be found directly below the signature date statement.   In addition to his or her signature, the Principal is required to print his or her full name on the “Print Name” line.  

 

Step 14 – Obtain Witness Testimony For This Signing

The Witnesses observing this document must each read the testimonial just under the title “Witnesses/Notary Acknowledgment” section then agree by signature to its content. To do this, the first Witness must sign his or her name on the first line of the “Witness 1” section, then document the signature “Date” beside it.  In addition to signing this testimony, Witness 1 must find the “Print Name” line below his or her signature then produce the printed version of his or her name.  The second Witness must also read the Witness statement the verify its accuracy by signing and dating the “Signature” and “Date” line in the “Witness 2” section.  Finally, Witness 2 must print his or her name on the line labeled “Print Name”  

 

Step 15 – The Process Of Notarization Will Verify This Execution

As mentioned earlier, the “Witness/Notary Acknowledgment” section contains a section where the Notary Public overseeing the Principal’s execution can subject the executed directive(s) to the notarization process. The “Notary Acknowledgment” section will be tended to after the signing and must contain the Notary Public’s testimony as to the location and day of the signing as well as the identity of the Principal. When reviewing this information make sure the Notary’s name and seal have been presented properly.   


ABOUT SSL CERTIFICATES