Alaska Advance Health Care Directive Form

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An Alaska advance directive is a document that allows a person to choose up to 2 health care agents to act in their place if they should not be able to speak for themselves. In addition, there is a section that lets a person decide their medical treatments if they should be in a state of permanent incapacitation with no cure. After signing, the form should be kept in a safe and accessible place with the health care agents aware of its location.

Table of Contents


Statute – AS 13.52.010

Signing Requirements (AS 13.52.010(b)) – Notary public or two (2) witnesses.

State Definition (AS 13.52.390(1)) – “Means an individual instruction or a durable power of attorney for health care.”


There is only a State registry for organ donation. An advance directive must be kept by the parties. (AS 13.52.177)

Versions (4)

Alaska Division of Public Health

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Institute for Human Caring

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Mental Health Advance Directive

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Providence Health

Download: Adobe PDF




How to Write

Download: Adobe PDF

1 – Opening The Form

Select any of the three buttons under the form preview image on this page. Each is labeled with the file type the form is available in. You may download or open this form at your discretion.

2 – Designating A Health Care Agent

Locate the first blank space, after the Title, then enter the Full Name of the Health Care Agent the Principal is appointing with decision making Power.

The Complete Residential Address of the appointed Health Care Agent must be presented on the second empty line on this form.

On the third blank line, record an up-to-date Contact Telephone Number well-maintained and answered by the Health Care Agent.

The Principal may designate two Alternate Agents who may successively step into the role of Principal Health Care Agent should the Primary Health Care Agent’s Principal Authority terminates. Each will have his or her own section to be named. In the first section, “Designation of First Alternate (Optional),” enter the Name of the First Alternate Agent to assume Principal Power on the first blank line.

Then on the second blank line, report the Address, City, State, and Zip Code of the First Alternate Agent’s Home Address.

The last blank space of this section must have a reliable Contact Number where the First Alternate Agent may be reached.

Locate the heading “Designation of Second Alternate (Optional), then enter the Name, Street Address, and Contact Telephone Number where the Second Alternate is found. This will be the individual to assume Principal Power if the Primary Health Care Agent and First Alternate Agent cannot or will not act as the Principal’s Agent.

3 – Outlining The Agent’s Authority

In Section (2) the Principal should state any limitations, restrictions, or provisions the Power being granted to the Health Care Agent.

Section (3) will define when the Health Care Agent will have Principal Power. If the Health Care Agent will not have Principal Power until a Physician declares the Principal unable to make his or her own decisions, then leave the check box in this section unmarked. If the Principal intends the Health Care Agent to have Principal Power immediately, then mark the check box in this section.

The next item requiring attention is Section (6) where the Principal will declare his or her preferences concerning end-of-life decisions. The Principal will need to choose either Choice (A) or Choice (B).

4 – Defining The Principal’s Preferences

If the Principal wishes his or her life prolonged for as long as possible then Choice A must be selected.
If the Principal imposes limitations to whether his or her life should be prolonged, then select Choice B. If you have selected Choice B, then mark the box labeled “(i)” to indicate the Principal does not wish his or her life Prolonged only if in a condition of permanent unconsciousness. If the Principal does not wish his or her life prolonged if stricken with a Terminal Condition, then mark box “(ii).” The box labeled “Additional Instructions” has been provided in case the Principal has conditions or provisions affecting the prolonging of his or her life. If so, several blank spaces have been provided to this end.

Item (C) will deal specifically with the Principal’s wishes regarding Artificial Nutrition and Hydration. That is, what should be done when the Principal cannot eat or drink independently. Several statements have been provided, only one may be selected.

If the Principal wishes to be artificially fed liquid and nutrients, mark the first box.

If the Principal wishes to be artificially given liquid and nutrients only so long as it is in his or her best interest and does not increase suffering, then mark the second box.

If the Principal will only allow artificial nutrition and delivery of liquid for a limited trial basis (to see if there is an improvement in health), then mark the third box.

If the Principal does not wish to receive artificial nutrition and hydration, then mark the fourth box.

If the Principal has a set of conditions, criteria, or instructions regarding Artificial Nutrition and Hydration then mark the fifth box and record such wishes on the blank lines following “Other instructions.”

Item D will focus on the Principal’s stance on Relief from Pain.

If the Principal wishes to receive treatment focusing on pain management when required, then mark the first box.

If the Principal has specific instructions regarding Pain Management, then mark the second box and document these instructions on the blank line provided.

Item E has been provided in cases of pregnancy. The Principal’s instructions in case she becomes unconscious while pregnant must be provided on the blank lines provided.

Section (7) has been provided in the event the Principal has additional provisions, instruction, terms, limitations, restrictions, and/or extensions to the Decision Making Powers of the Health Care Agent. If the Principal has concerns that have not been discussed thus far, they may be documented on the blank lines in this section.

5 – Determining Preferences Regarding Anatomical Gifts

Part 3 is optional, however if the Principal does have preferences regarding organ donation they may be covered in “Anatomical Gift At Death.”

In Item (8) mark Choice (A) if the Principal wishes to donate organs/tissues/other regardless of the body part, recipient, or purpose.

If the Principal only wishes to donate specific body parts, then mark Choice (B) and record which organs, tissues, and/or body parts the Principal will donate in the space provided.

If the Principal will only donate his or her organs/tissues/body parts for a specific purpose, then select Choice (C). This choice will require a definition to the approved purpose(s) by marking one or more of the appropriately labeled boxes. Four descriptions are available: “(i) transplant,” “(ii) therapy,” “(iii) research,” and/or “(iv) education”

If the Principal does not wish to make an anatomical gift of any sort, then mark the check box for Choice (D).

6 – Defining The Principal’s Preferences With Mental Health Issues

Part 4 is optional and will focus purely on Mental Health Treatment. The Principal should be made to understand that unless that specific court guidelines for being declared mentally incompetent have been met, he or she will be considered capable of making his or her own decisions.

The Principal may exert control over which medications may be administered in Item (9). If the Principal wishes to consent to specific medication, then mark the first box and report the Principal Approved Medications on the blank line.

If the Principal does not want to receive certain medications, then mark the second box and document the medications the Principal does not consent to receiving. Notice that an additional set of lines, labeled “Conditions or limitations,” so that additional information may be provided if necessary.

Item (10) will provide an area to document the Principal’s instructions regarding Electroconvulsive Treatment. If the Principal gives his or her consent to receive Electroconvulsive Treatment, the first box should be marked. If the Principal does not give consent, then mark the second box. Note: If there are Conditions or Limitations that apply to the Principals wishes, they may be reported on the blank lines.

Item (11) seeks to solidify the Principal’s wishes regarding his or her Admission To and Retention In a Facility. If the Principal consents to being admitted to a mental health facility for treatment, then mark the first box and enter the maximum amount of days his or her consent remains valid (must be less than 17).

If the Principal does not consent to being admitted to a mental health facility, then mark the second box. The blank lines labeled “Conditions or limitations,” will allow for any specific Principal preferences to be reported.

The next section, “Other Wishes Or Instructions,” provides an area so that any topics, preferences, or limitations regarding the Principal’s wishes, the granting of Power, or the Health Care Agent may be set and documented.

7 – Identifying The Primary Physician

Part 5 will accept the Principal’s Physician information, if this is available. This part of the form is optional and may be filled out at the Principal’s discretion.

In Item (12), on the first line, labeled “(name of physician),” enter the Name of the Principal’s Primary Physician. This should be followed by the Primary Physician’s Address and Telephone Number. 

There will be an additional option where a Second Primary Physician may be (in case the first one cannot or will not act as such). Use the blank lines in under the statement beginning with the word “Optional,” to report the Name, Address, and Contact Telephone Number of the Principal’s second choice for Primary Physician.

8 – Providing Validation For The Principal’s Decisions

This document must be Signed by the Principal in order for it to be validated. Furthermore, it must be substantiated either by two Witnesses or by Notary. To begin, locate Item (14). Here the Principal must enter the Date of Signature on the blank line labeled “Date.”

Next to the Date line, the Principal must sign his or her name in the space provided.

Below the Signature Date and Signature, the Principal’s Birth Date must be displayed.

The Principal’s Printed Name and Address must be presented in the appropriate areas below the Principal’s Birth Date.

9 – Substantiating Principal Signing

If Verifying Principal Signing With Witnesses

If the Principal Signing shall be verified by Witnesses who agree with the criteria discussed, in the acknowledgement statement in the “Alternative No. 1” paragraph, each Witness will need to read the Acknowledgment Statement and provide the Signature Date, his or her Signature, Printed Name, and Address in the space provided.

If the Principal Signing shall be verified by a Notary Public, the Notary Public will need to supply the items requested on the page labeled “Alternative No. 2” then provide the notarization seal.

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