Alabama Advance Directive Form

Create a high quality document online now!

An Alabama advance directive allows an individual to select someone else to make health care decisions on their behalf and to decide life-ending treatment options. This is a form primarily used for those in riskier health situations and the elderly. After signing, it should be kept in a safe and accessible place in the event of an emergency.

Advance Directives Include

  • Section 1. Living Will
  • Section 2. If I Need Someone to Speak for Me
  • Section 3. The Things Listed on this Form are What I want.
  • Section 4. My Signature
  • Section 5. Witnesses (Need 2 Witnesses to Sign)
  • Section 6. Signature of Proxy

Table of Contents

Laws

Statute – § 22-8A-4

Signing Requirements (§ 22-8A-4(c)(4)) – Two (2) witnesses of at least 19 years old and can’t be the agent or related to the principal by blood, marriage, or someone entitled to any portion of the principal’s estate or the person paying for the principal’s medical care.

State Definition (§ 22-8A-3(3)) – “A writing executed in accordance with Section 22-8A-4 which may include a living will, the appointment of a health care proxy, or both such living will and appointment of a health care proxy.”

Versions (5)


 

Alabama Hospital Association

Download: Adobe PDF

 

 

 


 

Baptist First

Download: Adobe PDF

 

 

 


 

Homestead Hospice

Download: Adobe PDF

 

 

 


 

Huntsville Hospital

Download: Adobe PDF

 

 

 


 

Spanish (Español)

Download: Adobe PDF

 

 

 


How to Write

Download: English (Adobe PDF), Español (Adobe PDF)

Section 1. Living Will

(1) Alabama Principal Declaration. The initial statement of the first portion of this directive seeks confirmation of the Principal’s identity. Produce your name as the Party who will set your medical preferences to paper for Alabama Medical Staff to review when you are incapacitated or unable to communicate yet need to deliver consent or refusals of treatment. If you are aiding or representing the Principal, then report his or her name.

When Terminally Ill Or Injured

(2) Your Life-Sustaining Preferences. Since this document will serve as your voice regarding treatment options when you are terminally ill or injured and unable to communicate, your direct input will be needed beginning with your preference regarding life-sustaining treatment. Your initials will serve as the manner in which you will approve of receiving Alabama Medical Staff’s life-sustaining treatments and procedures when these are necessary to prolong your life or to deny such procedures by simply initialing the “Yes” or “No” line provided.

(3) Your Directives On Artificial Nutrition. Another procedure that Alabama Doctors will seek your consent before administering is the artificial delivery of food and water through a tube or an IV. Place your initials to indicate your consent or your refusal to Alabama Medical Staff seeking to administer food and water using such methods. It should be noted that if selecting “No,” then you may run the risk of dying from starvation or dehydration if you are incapacitated for a significant period of time.

When Permanently Unconscious

(4) Life-Sustaining Instructions. If you are rendered permanently unconscious and your body requires assistance to perform functions vital to life in the State of Alabama then, by default, Physicians and Medical Personnel will seek to prolong your life through life support or life-sustaining procedures (i.e., breathing apparatus or dialysis machine). You may either provide consent now through this document or you may inform Alabama Physicians that you refuse to allow life-sustaining procedures or treatments administered when you have been rendered permanently unconscious. 

(5) Artificial Nourishment Directives. In addition to your life-sustaining instructions when permanently unconscious, your preferences on receiving nourishment and fluids through an IV or by tube should be defined. As with the previous directives, this requires your initials to either deliver consent or refusal to receiving artificial nourishment when permanently unconscious and unable to eat or drink independently.

Other Directions

(6) Your Specific Directives. The above directives are considered basic issues when you are diagnosed with a terminal (incurable) condition or are permanently unconscious. However, as the Alabama Patient, you may address other issues as well. You may convey your conditions on when certain treatments would be acceptable and when they may not be acceptable, your standing on medications, or which terminal conditions warrant the use of this document and which do not. You are encouraged to speak to a licensed Physician before setting these instructions to paper. If and when you do, make sure a complete report is provided. An attachment is permissible if more room is needed.

(7) Additional Instruction Status. If you do not have other directions to include, then initial the statement closing this section to verify this to Reviewers. If this statement is left unattended, Alabama Physicians will seek the other instructions you provided in an effort to fully assess your medical preferences.

Section 2. If I Need Someone To Speak For Me

(8) Health Care Proxy Appointment. The State of Alabama also allows an appointment of your Health Care Proxy. This means that you may formally name a specific person to represent your medical interests in this state. This is an optional part of this form, but it is important that your decision to appoint an Alabama Health Care Proxy or to refrain from making this appointment is documented. Therefore, initial the statement that best represents your intention.

(9) First Choice For Proxy. Your first choice for Health Care Proxy should be appointed by documenting his or her entire name then recording the relationship your Health Care Proxy holds with you.

(10) First Proxy Choice Home Address.

(11) First Proxy Choice Phone Number(s).

(12) Second Choice For Proxy. If your first choice for Alabama Health Care Proxy is unable to act on your behalf with Physicians or is unwilling to then, you can be left without the representation you were relying on when incapacitated and in need of invasive medical treatment. You can offset the results of this possibility by naming a second choice for your Alabama Health Care Proxy.

(13) Second Proxy Choice Contact Information.

(14) Second Proxy Choice Phone Number(s).

Health Care Proxy Power

(15) Nutrition Directive And The Proxy. The decision to accept or deny the efforts of Alabama Doctors efforts to deliver nourishment and fluids artificially (i.e., using a tube) can be placed in the hands of your Alabama Health Care Proxy by initialing the statement best reflecting your preference. That is, initial “Yes” to deliver this authority to your Agent or initial the “No” line if you do not wish to grant your Alabama Health Care Proxy the authority to decide on the delivery of artificial nutrition and water.

(16) Health Care Proxy Status. The status held by your Alabama Health Care Proxy in relation to your living will should be clearly defined. One of four statements can be selected for this purpose. Thus, provide your initials to instruct the Health Care Proxy to follow the instructions on this form regardless of the situation you are currently in, allow your Health Care Proxy to follow the instructions on this form if they are appropriate while having the power to supersede them for unforeseen events or treatment options, or to give your Health Care Proxy the authority to override the directives you set in this form.

Section 3 The Things Listed On This Form Are What I Want

(17) Concerned Principal Parties. If you wish family members and other concerned Parties to be kept informed of this document in a scenario where your Health Care Proxy has determined that artificial nutrition and life-sustaining treatment be removed, then use the available space to list the names and contact information of the Parties that should be contacted and conferred with.

Section 4. My Signature

(18) Your Name. To effectively put this document in motion as an accurate and up-to-date representation of your medical preferences, you must provide a dated signature witnessed by two people (who are unrelated to you, not named as your Agent, and unaware of any entitlements or bequeathments). Print your name to begin this process.

(19) The Month, Day, And Year Of Your Birth. Verify your identity to reviewers by reporting your birth date.

(20) Your Signature. Sign your full name to this paperwork before two Witnesses.

(21) Date Signed. Produce the current calendar date once you have signed this document.

Section 5. Witnesses

(22) Name Of First Witness. Both Witnesses will need to attest to the fact that they qualify for this role in the State of Alabama as well as authenticating that your act of signing was performed by you. Before providing such a testimony, the First Witness must print his or her name.

(23) Signature. Witness 1 will sign this document if he or she can testify that the statement made regarding his or her qualifications and your signature is true.

(24) Date. Naturally, Witness 1’s signature date should be the same as yours.

(25) Second Witness Name And Signature. Witness 2 must print his or her name, sign this document to prove that the Witness’s testimonial above is accurate as well as provide a record of the current date.

Section 6. Signature Of Proxy

(26) First Choice Health Care Proxy Statement. Both of your Health Care Proxies should be given a copy of this paperwork for storage. Before it can be considered complete, the final section will require that your first choice for Health Care Proxy print his or her name to the contents of the provided statement, then sign and date this document to acknowledge the responsibility this role holds.

(27) Signature Of Second Choice For Proxy. Your second choice for Health Care Proxy should also complete a second acknowledgment statement with his or her printed name then sign and date this document to acknowledge the possibility of being called upon to take on the role of your Health Care Proxy in the state of Alabama.

 

Resources

Related Forms


Durable (Financial) Power of Attorney

Download: Adobe PDF, MS Word, OpenDocument

 

 

 


Last Will and Testament

Download: Adobe PDF, MS Word, OpenDocument