Ohio Advance Directive Form

Create a high quality document online now!

An Ohio advance directive is a document that allows a person to outline their health care treatment preferences and to select an agent to carry out the request. The agent is commonly a spouse or family member that can be trusted to follow health care preferences in the advance directive. The form is only to be used when a person has become incapacitated or unable to make decisions on their own.

Advance Directive Includes

Table of Contents

Laws

Statute§ 1337.60, § 2133.02

Signing Requirements (§ 2133.02(A)(1)) – Two (2) witnesses or a notary public.

Versions (3)


AARP

Download: Adobe PDF

 

 

 


Hospital Assoc.

Download: Adobe PDF

 

 

 


Spanish (Español) Version

Download: Adobe PDF

 

 

 


How to Write

Download: Adobe PDF

Step 1 – Obtain The Ohio Advance Directive

The Ohio Advance Directive is available as an “Adobe PDF” file. Download this file using the link above or the “PDF” button presented with the image on this page.

Step 2 – Complete The Checklist Introducing This Package

The first page of this document displays a checklist that should be reviewed then completed when the forms on this page have been properly executed. Use the corresponding “Yes” or “No” checkboxes to indicate if a Health Care Power Of Attorney has been dispensed. In our example, the Health Care Power Of Attorney will be executed in this package thus, the “Yes” box has been selected. 

If the concerned Health Care Power Of Attorney will be executed with “Special Notes” and/or includes a Nomination Of Guardian, then select the second and third “Yes” boxes from this list. If not, select the corresponding “No” box. Below, both items will be included in the issued Health Care Power Of Attorney. 

 

If a Living will Declaration will be issued, then select the fourth checkbox labeled “Yes” otherwise, select the “No” box. 

In a case where “Special Instructions” will be included, select the “Yes” checkbox for the final statement. If not, then the “No” statement should be selected. In our case, a Living Will with Special Instructions shall be included. 

Step 3 – Supplement The Title Of The Ohio Appointment With Principal Information

When it is time to complete the Ohio Health Care Power Of Attorney to grant an Agent with the authority to act as your Attorney-in-Fact or Representative over health care decisions in the State of Ohio. Produce your name on the first blank line under the title of this form labeled “Full Name.” 

Continue through this title where a recording of your “Birth Date” should be furnished. 

Step 4 – Read Through The Introduction To Familiarize Yourself With The Ohio Document

The first two pages following the title and the declaration statement below it will present valuable information pertaining to this form. This is a preview of the terms it used when designating another person to make health care decisions on your behalf when incapacitated and requiring medical attention from Ohio Medical Personnel. 

Step 5 – Formally Designate The Ohio Attorney-In-Fact

Your Health Care Agent or Medical Attorney-in-Fact should be clearly appointed with this role at the onset of this form. The area beginning with the bold statement label “Naming Of My Agent” displays the designation language needed for this purpose while the blank line below it, labeled “Agent’s Name And Relationship” seeks the full name of the person who you expect Ohio Physicians to consult with to determine your medical treatment if you are unable to answer questions or communicate. In addition to naming this person, document how this person is related to you. 

The second blank line requests the “Address” where the Medical Attorney-in-Fact or Ohio Health Care Agent’s home can be visited. 

Complete identifying the Medical Attorney-in-Fact or Ohio Health Care Agent by listing every “Telephone Number(s)” where he or she can be reached when Ohio Medical Providers must contact your Ohio Health Care Agent or Attorney-in-Fact. 

Step 6 – Provide Direct Authorization For Your Ohio Health Care Agent’s Medical Record Access

The first box underneath your production of the Medical Attorney-in-Fact or Ohio Health Care Agent’s identity (and contact information) corresponds to a statement declaring your intent to allow the Ohio Health Care Agent named above to access your “Protected Health Care Information Immediately And At Any Future Time.” This statement can only be applied to your Ohio Health Care Agent’s ability to access your medical records if you provide initial approval in the box to the left. Provide your initials to grant this power to your Agent. 

Step 7 – Attach Alternate Agents To Succeed An Ineffectual Or Unwilling Attorney-in-Fact

Unfortunately, there may be times when your choice of Ohio Health Care Agent cannot act because he or she has stepped down, had his or her power revoked, or cannot be contacted for an extended period of time. Such circumstances can place you in need of medical attention, unconscious, and without the representation you will be dependent upon. This result can be handled by already naming an individual to succeed the Ohio Health Care Agent you chose. To complete this action, locate the line labeled “First Alternate Agent’s Name And Relationship” then supply it with the full name of the Successor to your Ohio Health Care Agent and the relationship he or she shares with you. 

The “Address” and “Telephone Number(s)” lines should be used to display the methods needed to contact your Alternate Agent’s home address and any phone number needed to contact him or her at any time of day. 

You may have noticed that the previous appointment is for a First Alternate Agent. This is because an additional precaution will be taken. If the Ohio Health Care Agent and the First Alternate Agent will not be able to or cannot represent your medical needs when unconscious, then a Second Alternate Agent can be approached for the Medical Attorney-in-Fact or Ohio Health Care Agent roll so long as you identify this individual and the relationship you hold with him or her on the blank line labeled “Second Alternate Agent’s Name And Relationship.” 

The two lines that follow the Second Alternate Agent’s name, should be furnished with the home “Address” and contact “Telephone Number(s)” needed to reach this individual.

Step 8 – Review The Granted Authority Of The Ohio Health Care Agent For Approval

Several items are placed in the “Authority Of Agent” section that bear review by the Ohio Principal issuing this appointment. Any item that defines an action or decision-making process that the Ohio Principal will not authorize his or her Medical Attorney-in-fact to undertake on his or her behalf should be struck through with a solid line.  Review the introduction to this area before proceeding.  Item “1. To Consent To The Administration Of Pain-relieving Drugs Or Treatment Or Procedures…” should be struck through if the Principal does not want the Ohio Attorney-in-Fact to have this kind of control over his or her treatment. If the Principal is comfortable with the Ohio Health Care Agent wielding principal power for this purpose, then this statement should be left intact. In the example below this statement has been struck through indicating that the Principal has issued a specific set of instructions or that he or she wishes this decision in the hands of the attending Ohio Physician.  The second item gives the Ohio Health Care Agent the ability to make treatment decisions for the Principal if the Principal is suffering a terminal or fatal condition and has not issued a living will. In the example below this statement is left intact and will thus apply. If the Principal wishes to give the Ohio Health care Agent the authority “To Give, Withdraw Or Refuse To Give Informed Consent…” to medical treatments on his or her behalf then the third item should be left intact as in the example below. The fourth item should be included if the Ohio Principal wishes to give his or her Medical Attorney-in-Fact access to his or her information regarding the Principal’s mental and physical health. This can be removed with a solid line or left intact to apply. In the example below, it is left intact and thus will be within the scope of the Ohio Health Care Agent’s principal authority. The Medical Attorney-in-Fact will be able to use the language in the sixth item to disclose the Principal’s other information for the purpose of obtaining the Principal’s medical information. The seventh item allows the Medical Attorney-in-Fact (or the Health Care Agent) “To Execute Consents, Waivers And Releases Of Liability…” on behalf of the Principal when necessary to obtain compliance from anyone depending upon this document for guidance on the Principal’s wishes. This statement has been struck through in our example. Notice how each line has been struck through with a solid line. The Principal will grant the Ohio Health Care Agent the right “To Select, Employ And Discharge Health Care Personnel And Services” on behalf of the Principal. This statement is left intact so it will apply to the Medical Attorney-in-Fact’s authority. The ninth item of this list authorizes the Principal’s medical Attorney-in-Fact the power to take charge of his or her admittance and discharge from “…Any Medical Or Health Care Facility, Including But Not Limited To, Hospitals, Nursing Homes, Assisted Living Facilities, Hospices, Adult Homes…” and other such institutions that can provide the Principal medical treatment or comfort care. Notice this statement has not been struck through so it will be applied to the actions authorized by the Principal.  If the Principal approves of the Ohio Attorney-in-Fact’s authority to transport or arrange transportation from a Medical Facility that does not honor this document to a Medical Facility that will (obey this directive) then the tenth item should be left intact. The eleventh item authorizes the Ohio Health Care Agent to undertake several actions on his or her behalf. If the Ohio Health Care Agent will be authorized to consent to health care treatments and issue orders such as a DNR (Do Not resuscitate), sign papers to handle facility transfers, discharges, or admittance, and carry out any other decision necessary to enforce this document. Notice our example the Medical Attorney-in-Fact will have all of the defined powers but will not be able to issue a DNR on behalf of the Principal.

 

Step 9 – Indicate If the Ohio Health Care Agent’s Principal Powers Extend To Medically Provided Nutrition/Liquids

If, as the Ohio Principal, you do not issue a living will, but you prefer that your Health Care Agent (or Medical Attorney-in-fact) decide upon whether or when it is appropriate for Ohio Medical Staff to monitor and maintain your nutrient and fluids lever then mark the checkbox underneath the title “Special Instructions.”

 

Step 10 – Review The Limitations Ohio Law Places On Your Health Care Agent’s Principal Powers

Ohio State Law will place certain restrictions upon your Medical Attorney-in-Fact or Health Care Agent when representing your interests to Medical Staff. These protections are listed in sections beginning with the bold phrase “Limitations Of Agent’s Authority” Review these points.  If desired, “Additional Instructions Or Limitations” can be placed on the Ohio Health Care Agent or Attorney-in-Fact’s scope of principal authority. The text box at the bottom of page five shall accept such instructions as delivered directly by the Principal. Here, any requests regarding medical care, preferences regarding your Attorney-in-Fact’s decision-making process, or even restrictions on granted authority to prevent your Ohio Health Care Agent from mistakenly issuing a decision you would not support. You may use an attachment whose title is cited in this box if more room is needed or, if no “Additional Instructions Or Limitations” are necessary then record the word “None” in this box to verify the Principal’s approval. 

 

Step 11 – Indicate If The Ohio Health Care Agent Carries The Principal’s Nomination For Guardian Of Person

The next page engages a discussion on the possibility of Ohio Courts appointing a Guardian over your person. This is a Party that will make sure that your day-to-day needs are met in your personal live (i.e., living arrangements). Read through the “Nomination Of Guardian” section to further discuss this type of Agent.  If desired, you may nominate your Ohio Health Care Agent (Medical Attorney-in-Fact) or one of your Successor Agents to this role by reading this page then seeking the checkbox corresponding to the words “By Writing My Initials, Signature, As Check Mark Or Other Mark In this Box…” then supplying your initials of approval to its content (recommended) or a mark such as a check. The Ohio Principal being discussed also reserves the ability to nominate a separate party altogether to the role of Court Appointed Guardian. If this is desired, then identify your Nomination on the blank line labeled “Guardian Of My Person’s Name And Relationship” by documenting his or her full name and how he or she knows you (the Principal). The “Address” needed to contact your Nomination as well as his or her “Telephone Number(s)” should be displayed next. Provide these items on the next two lines.  It is also suggested that you elect a second Nomination for the role of Guardian to avoid any delays should your primary Guardian decline or be unable to fill this role. Nominate a second choice for Guardian by naming him or her and discussing the relationship shared with you (the Principal) on the line labeled “Alternate Guardian Of My Person’s Name And Relationship”Continue nominating the Alternate Guardian by recording his or her contact information to the “Address” and “Telephone Number(s)” line. Generally, it is wise to make sure that your Nominated Guardian acts appropriately. You could elect to have him or her on a court order bond to avoid the possibility of him or her taking advantage of the position held as your Guardian. You can waive this requirement by marking the checkbox below your appointment or request the Guardian or Successor Guardian nominated through this document is bonded to the courts by leaving this checkbox blank. In the example below Guardian will not require bonding. Before proceeding with the execution of this power of attorney locate the final checkbox choice. This can be found at the end of page seven as the statement “I Have Completed A Living Will Declaration.” If this is the case (see example below) then mark the checkbox labeled “Yes.” If not, you may select the “No” checkbox. 

 

Step 12 – Date The Principal’s Final Review And Execution Of This Designation

The “Signature Of The Principal” page makes a declaration that you, as the Ohio Principal, fully comprehend the contents of this document and that you have approved them. Review the statements here then supply the date of this paperwork’s signing (by the Ohio Principal) at the end of this section using the first blank line after the sentence “I Sign My Name To This Health Care Power Of Attorney On…” then produce the Ohio City and Ohio County where the signing occurs on the blank line before the word “Ohio.” The Ohio Principal must sign the blank line labeled “Principal” on the signature date indicated above at the defined location.  This designation must be signed before two Witnesses and a Notary Public. The Witnesses involved can only qualify for this role if neither is the Ohio Principal’s Agent, Guardian, Alternate Successor Agent or Guardian, a blood/marriage/adoption relation, the attending Principal, or anyone employed or operating a Care Facility responsible for the Principal’s health. Both qualifying Witnesses must take control of this document after the Principal signing. The first line below the testimony is divided by the labels “Witness One’s Signature,” “Witness One’s Printed Name,” and “Date” where the first Witness must sign and print his or her name as well as report the “Date” of signature.  The first Signature Witness must deliver his or her address on the “Witness One’s Address” line. After completing his or her testimony, Witness One must give this document to the other Witness in attendance. The second Witness must sign his or her name just above the words “Witness Two’ s Signature” then print his or her name above the words “Witness Two’s Printed Name” line. The second Witness section requires that the date when Witness Two supplies his or her signature is recorded next to the signature and printed name before proceeding with a production of his or her address on the line below this. The “Notary Acknowledgment” section is only available for the use of the Notary Public verifying this document. 

 

Step 13 – Review the Ohio Living Will’s Introduction

Ohio allows a living will to be issued and applied as a Patient’s medical instructions when he or she cannot communicate or deliver informed consent sought by Ohio Medical Personnel and is also suffering from a fatal condition or permanently unconscious. Such topics will be covered in the introduction to the “Ohio Will Declaration” and should be read to comprehension by the Ohio Declarant using this form to dictate his or her medical treatment preferences. 

 

Step 14 – Supplement The Declaration Title With The Patient’s Information

The title for the Ohio Living must identify the future Patient issuing his or her directives. The “Full Name” line directly after the words “Ohio Living Will Declaration” must be furnished with the name of the Patient this document concerns.  The “Birth Date” line in this title requires the month, two-day calendar day of the month, and the year of the Patient’s birthday produced as its content. 

 

Step 15 – Read Through Some Preliminary Information Before Continuing

The first paragraphs of this document will define the terms presented in this document for the benefit of the Declarant as well as anyone reviewing its contents. It is imperative that the Patient making this declaration fully comprehend each term listed. If the Patient or Ohio Declarant has completed and issued a “Health Care Power Of Attorney” then the “Yes” box should be marked after the statement “I Have Completed A Health Care Power Of Attorney.” If not, then the “No” box should be selected. 

 

Step 16 – Name An Emergency Contact Person For The Patient

If there comes a time when attending Ohio Physicians have determined this document must be used to determine the Declarant’s wishes and that life support systems will be withheld from the Patient or withdrawn (by consent through this document) then they will make some efforts to contact at least one family member or friend of the Patient’s choosing. The “First Contact’s Name And Relationship” line will accept the name of the first Person Ohio Medical Staff will seek to inform of the Patient’s condition. A record of the relationship held between this contact and the Declarant should also be distributed to this line.  The home “Address” of the First Contact and his or her current “Telephone Number(s)” should be dispensed to the next line.  As mentioned earlier, a Second Contact will be expected. Place this person’s name and a description of the relationship held with the Ohio Patient or Declarant on the line labeled “Second Contact’s Name And Relationship.”  The “Address” as well as the “Telephone Number(s)” maintained by the Second Contact Person should be distributed down the two lines before this Party’s name. A Third Contact can be listed using the lines labeled “Third Contact’s Name And Relationship,” “Address,” and “Telephone Number(s).”

 

Step 17 – Review The Formal Declaration Being Made To Ohio Physicians

The text that follows shall establish that the Ohio Patient or Declarant expects this document to be put in effect when he or she cannot make decisions regarding health care or is permanently unconscious and has been diagnosed with a terminal disease while in this condition. When this happens the Ohio Declarant will automatically authorize the Physician to issue a DNR, remove life support systems, and take appropriate actions to ensure the Declarant experiences a natural death in comfort. 

 

Step 18 – Formally Display The Ohio Declarant’s Treatment Preferences For Malnutrition Or Dehydration

The checkbox under the heading “Special Instructions” should be checked if the Ohio Patient (or Declarant) wishes that his or her attending Physician withdraw or deny artificial nutrition/hydration when he or she is unconscious or in a permanent vegetative state, is close to an end-of-life event, and whose pain and comfort remains unaffected by medically assisted feedings and hydration. If this box is left unmarked then, by default, Ohio Medical Staff will continue to monitor the Patient’s nutrition and hydration levels and keep them well maintained until the point of death.  “Additional Instructions Or Limitations” can be applied to the treatment the Ohio Patient expects when rendered unconscious/uncommunicative with little hope of recovery and near an end of life event in the text box provided on this page. If no additional instructions are needed, then the word “None” should be displayed in this text box. 

 

Step 19 – Document The Ohio Declarant’s Willingness To Make An Anatomical Gift

The “Anatomical Gift” page is optional and may be included with the Ohio Declarant’s living will. If the Ohio Patient has decided that he or she will make an anatomical gift after death, then this desire should be defined in “Section 1. Body Parts.” If the Declarant will donate “All Organs, Tissues, and Eyes” then the first checkbox should be selected. This checkbox should be left blank if the Declarant intends to only donate certain organs and body parts.  If the Ohio Declarant only wishes to donate certain body parts, then the list provided should be reviewed. Every checkbox corresponding to an organ or body par  t authorized for donation must be marked. For instance, in the example below the Ohio Patient authorizes a donation of his or her “Heart,” “Lungs,” “Bone,” and “Tendons.” “Section 2 Purposes” seeks the Ohio Declarant’s approved purpose for the anatomical donation being discussed. If the Ohio Declarant will approve the concerned donation for “All Purposes” then he or she should select the first checkbox presented.  The Ohio Declarant can authorize specific anatomical gift goals from the checkboxes labeled “Transplantation,” “Therapy,” “Research,” or “Education” In the example below the Declarant will authorize anatomical donations made for “Transplantation” and “Therapy,” but not for “Research” or “Education” purposes. 

 

Step 20 – A Valid Signature From The Ohio Declarant Must Be Displayed

The date when this paperwork is executed must be provided at the end of this form. Locate the statement “I Sign My Name To This Living Will Declaration On…” then supply the date of signing then the Ohio city and country where this takes place.  The “Declarant” line requires that the Ohio Patient sign his or her name on it before two Witnesses or an Ohio Notary Public.  The Witnesses observing the Ohio Declarant’s signature should read the affirmation statement that this act was performed in good faith and with informed consent. The first signature line presented beneath this bold statement is labeled “Witness One’s Signature” in its first part. The Witness must sign his or her name then proceed to supply his or her printed name and signature “Date” where it is requested.  The next requirement placed on Witness One will be to disclose his or her residential address on the “Witness One’s Address” line.  Witness Two must take control of the document then also agree with the testimonial by signing. This acknowledgment must be provided by his or her signature on the line labeled “Witness Two’s Signature.” Furthermore, Witness Two must supply his or her printed name and signature “Date” to the remainder of this line.  “Witness Two’s Address” is expected on the next line down.  If the Ohio Declarant has decided to provide “Notary Acknowledgement” of his or her signing, then the next section must be completed by the Ohio Notary Public attending the signing. He or she will document the location, date, and Declarant identity for this signing then notarize these facts with his or her credentials. 

 

Step 21 – Optionally Enroll In The Ohio Donor Registry

The Ohio Donor Registry Enrollment Form is optional but is recommended if a desire to make an anatomical gift has been established. The Declarant only needs to fill in his or her full name to the top row to begin  In addition to his or her name, the Ohio Organ Donor should document his or her full mailing address using the next two rows as a guide.  The Ohio Organ Donor should conclude self-reporting with a record of his or her “Phone” number, “Date Of Birth” and State Of Ohio Driver’s License numbers, State ID Number, or Social Security Number on the final row of the table.  Once he or she has completed this task, the “Donor Registry Enrollment Options ” table’s first box must be checked to verify the Ohio Organ Donor’s intent to make anatomical gifts. Option 2 requires the Ohio Donor to mark the box labeled “Upon My Death, I Make An Anatomical Gift…” then to either mark the “All Organs, Tissues And Eye” checkbox to indicate that Donor’s approval to donate all organs and body part or to use the list below to indicate which organs and body parts can be donated with his or her authorization. In the example below, the Organ Donor will donate “All Organs, Tissues And Eyes.”  If only some organs or body parts bear the Ohio Declarant’s approval then the checklist provided can be used to document this decision. The example below shows a Donor who wishes to make anatomical gifts of his or her “Heart,” “Bone,” and “Tendons.”In addition to defining what the Organ Donor approves as an anatomical gift, he or she will be expected either select the “All Purposes” checkbox to demonstrate that any purpose for his or her anatomical gift to be made or to select every box that defines an authorized purpose. In the example below, the Ohio Organ Donor only approves of his or her anatomical gifts made for “All Purposes” Option 3 allows the Organ Donor to be taken out of the Ohio Organ Donor Registry once he or she marks the checkbox contained in this option.  To execute the Organ Donation Registry Form, the Organ Donor must locate the “Signature OF Donor Registrant” box then sign it. After completing this task, the “Date” box must be supplied with the Organ Registrant’s signature date. 

 

Step 21 – Attend To the Ohio DNR Comfort Care Declaration

The “DNR Comfort Care” form allows an Ohio Physician to document the Ohio Declarant or future Patient’s directives when found needing cardiopulmonary resuscitation. The first tasks set here will be in the boxes labeled “Patient Name” and “Patient Birth Date” in the boxes on the top row.  The Ohio Patient executing this directive or an Authorized Agent that he or she is working through should sign the box labeled “Patient Or Authorized Representative’s Signature.” This box may be considered optional if the Patient is unconscious or unable to sign his or her name.  The “Printed Name Of Physician, APRN, Or PA” box requires that the full name of the Ohio Medical Provider filling out this form with the Patient is presented for display while the next box (labeled “Date”) seeks the date when the DNR is being completed. The “Signature Of Physician, APRN, Or PA” box must be signed by the Ohio Health Provider filling this form out with the Patient. This Party may be a Physician, Registered Nurse, or Physician’s Assistant. After signing this paperwork, the Signature Medical Provider must supply the “Phone” number where his or her office can be reached. If the Ohio Physician responsible for the Patient’s care is not the signature party, then it must be printed in the box labeled “Required For APRN Or PA.” If either a Registered Nurse or Physician’s Assistant is completing and signing this form then the Supervising Physician must have his or her Name and Ohio “NPI, DEA, or Medical License Number” furnished to this box.   Once this paperwork is issued, Ohio Medical Providers will understand the Patient does not wish CPR used, administer any kind of medication with the expectation of restarting the heart or lungs, intubate if needed, engage in cardiac monitoring or try to restart and maintain the heart through defibrillation, cardiovert, or initiate pacing while still performing medical care, provide comfort (i.e. CPAP or BIPAP), maintain hydration and pain medication with an IV if necessary, and contact necessary health care providers for end-of life events. If this level of care should not be provided until the Patient goes into cardiac arrest and the Patient should be treated as any other, then mark the “DNR Comfort Care – Arrest” box. If the Patient wishes the DNR Protocol to go in effect immediately then select the “DNR Comfort Care” box. 

 

Related Forms


Durable (Financial) Power of Attorney

Download: Adobe PDF, MS Word, OpenDocument

 

 

 


Last Will and Testament

Download: Adobe PDF, MS Word, OpenDocument