North Dakota Advance Directive Form

Create a high quality document online now!

A North Dakota advance directive is a document that allows a person to appoint a health care agent to take care of their medical needs and make end-of-life treatment plans. An advance directive lets a person make their medical goals known to family members and medical staff. The agent selected is expected to align their decision-making process with the goals of the person who wrote them.

Four (4) Parts

  • Health Care Directive (‘power of attorney’);
  • Health Care Instructions (‘living will’);
  • Making an Anatomical Gift; and
  • Making the Document Legal.

Table of Contents


Statute§ 23-06.5-01 to § 23-06.5-19 (Health Care Directives)

Signing Requirements (§ 23-06.5-05) – Two (2) witnesses or a notary public.

State Definition – (§ 23-06.5-02(5)) – “Health care directive” means a written instrument that complies with this chapter and includes one or more health care instructions, a power of attorney for health care, or both.

Versions (5)

CHI St. Alexius Health

Download: Adobe PDF




ND.Gov Version

Download: Adobe PDF




North Dakota Medical Assoc.

Download: Adobe PDF




Jacobson Hospital

Download: Adobe PDF




Sanford Health

Download: Adobe PDF




How to Write

Download: Adobe PDF, MS Word, OpenDocument

1 – Obtain The North Dakota Health Care Agent Appointment

Download the paperwork on this page. It will provide the structure and language required to assign a Health Care Agent with the Principal Authority to make Health Care Decisions on behalf of the Principal in a variety of circumstances. It is available in one of three file formats as labeled by the buttons underneath the image. Select any of these buttons to download this form.

2 – Produce The Formal Health Care Agent Appointment

The first paragraph will begin a formal declaration of Health Care Agent assignment. First, furnish the First, Middle, and Last Name of the Principal. All parties involved should read the passage provided here.

After the initial passage (which the Principal should be sure to read) will be an area with several blank lines. This will be where we provide the identity of the Health Care Agent(s). Fill in the Full Name of the individual being named as the Health Care Agent on the blank line between the phrase “…I Trust And Appoint” and the words “…To Make Health Care Decisions For Me”The next sentence requires a report on the Health Care Agent’s relationship with the Principal (i.e. Cousin). Report this relationship on the blank space in the statement beginning with “Relationship Of My Health Care Agent…”Fill in the Health Care Agent’s Telephone Number on the blank line in the third sentence here.Finally record the entire Legal Address of the Health Care Agent on the blank space after the words “Address Of My Health Care Agent”The next area, “(Optional) Appointment Of Alternate Health Care Agent,” allows for a Health Care Agent to be held in reserve to wield the Principal Authority required to represent the Principal’s interests should the Health Care Agent, named above, be unable or unwilling to act in his or her role.3 – Reviewing The Default Principal Powers Delivered To The Health Care Agent

The next area requiring attention will be a list of the Decision-Making Powers and Actions the Health Care Agent will have the Principal Authority to engage in on behalf of the Principal. By default, the Health Care Agent will be able to “(A) Make Any Health Care Decisions” for the Principal, (B) choose the Principal’s Health Care Providers, (C) Choose where the Principal lives and receives Health Care, and (D) access and review any of the Principal’s Medical Records at-will as if he or she were the Principal. If the Principal wants to limit the Health Care Agent’s Principal Powers, then he or she should make such limitations or restrictions known. They must be reported using the blank lines below this list. Make sure when providing this report to do so by calling out the corresponding letter (A through D) to the Power Designation that should be restricted from Health Care Agent use.

4 – Address The Subject Of Anatomical Gifts

The Principal Powers regarding post-partum actions are not delivered by default through this document. Two statements (1 and 2) have been supplied to accept the Principal’s approval for such action. The Principal may initial either, both, or neither of these statements depending upon his or her preferences. If the Attorney-in-Fact should have the Power to decide upon Anatomical Gifts, the Principal should initial Statement 1. If the Attorney-in-Fact should have the Principal Power to decide what to do with the remains, the Principal should initial the Statement 2.If the Principal has any restrictions upon this, then he or she should make sure they are reported on the blank below this area in the blank lines provided

5 – Officially Provide The Principal’s Directives

The next part of this paperwork, “Part II: Health Care Instructions,” and arguably the most important, will give the Principal an opportunity to discuss and document his or her instructions to the Attorney-in-Fact first-hand. This section is optional, and if it is not filled out it will be assumed the Health Care Agent will know how to act in the Principal’s best interests. Most would consider it wise for the Principal to complete as much of this part as possible. To begin, locate the statement “My Goals For Health Care” then, record the Principal’s preferred guidelines for making decisions regarding his or her Medical or Mental Health CareNext, find the statement “My Fears About Health Care,” then report what the Principal believes is a cause for concern when receiving Medical or Mental Health Care using the blank line supplied below it.If the Principal has any Religious or Spiritual Beliefs that would affect, interfere, or prevent any types of Medical Treatments, they should be documented on the blank lines beneath the statement “My Spiritual Or Religious Beliefs And Traditions.”There may be scenarios of medical treatments or events where the Principal believes it would be better not to prolong life. Any such beliefs should be recorded under the words “My Beliefs About When Life Would Be No Longer Worth Living”The Principal’s ideas on how his or her Medical Care may affect his or her Family should be documented on the blank lines under the “My Thoughts About How My Medical Condition Might Affect My Family”

Now locate the statement beginning with the words “If I Had A Reasonable Chance Of Recovery…,” document the Principal’s instructions and expectations in a scenario where he or she needs Medical Care, is rendered incapacitated, and unable to make his or her own decisions on the blank lines supplied.The next statement, beginning with the phrase “If I Dying And Unable To Make And Communicate Health Care Decisions…” provides an area for the Principal to define what he or she prefers the Health Care Agent should consider a priority in the face of a life-threatening medical event.If the Principal has any directives in a scenario where he or she is in permanent vegetative state, they should be documented on the blank lines below the statement beginning with the words “If I Permanently Unconscious And Unable To Make And Communicate Health Care Decisions.”The Principal may have instructions for the Health Care Agent if or when rendered dependent on others to continue living while being unable to communicate. If so, such Principal Directives should be stated on the blank lines beneath the “If I Were Completely Dependent On Others…” statement.The Principal (by default) will expect some level of pain management should it be required. If the Principal has any instructions when pain management hinders his or her alertness or shortens his or her lifespan, such directives should be accurately documented in the space provided below the statement starting with the words “In All Circumstances, My Doctors Will Try To Keep Me Comfortable…”If the Principal has settled upon a specific Physician, then record this practitioner’s Name on the empty lines below the words “Who I Would Like To Be My Doctor”Similarly, record any facility where the Principal would insist on receiving medical care below the statement “Where I Would Like To Live To Receive Health Care”In a case where the Principal has instructions regarding where he or she prefers to die (or any directive regarding the subject of dying) then, record these preferences in the area under the statement “Where I would Like To Die And Other Wishes I Have About Dying”The Principal may have determinations about his or her own burial, cremation, etc. If so, an area underneath the statement “My Wishes About What Happens To My Body When I Die…” has been provided so that such directives may be delivered.If there are any provisions, instructions, or considerations the Principal wishes to be applied then document them beneath the words “Any Other Things”

6 – Addressing Anatomical Gifts

If the Principal is an organ donor then in “Part III: Making An Anatomical Gift” he or she should initial one of the statements provided to indicate his or her preferences. If the Principal is willing to donate any of his or her organs and tissues, the first statement should be initialed. If he or she only wishes certain organs, tissues, or body parts to be available for organ donation, the second statement should be initialed by the Principal and the authorized donated organs/tissues/body parts should be documented on the blank line.

7 – Execute This Paperwork As A Legal Document

The Principal must attend to the final section, so this Health Care Appointment can be executed. In “Part IV: Making The Document Legal,” the Principal should enter the Date he or she is signing this document on the blank space just after the statement “I Sign My Name To This Health Care Directive Form On…”Below the Execution Date just recorded, the Principal should supply the name of his or her City and State of Residence on the line labeled “City” and “State” (respectively).On the line just over the words “You Sign Here,” the Principal must sign his or her name.The next segment of this paperwork will give the Principal the opportunity to choose how this document may be substantiated as true. The Principal Signing must be either Witnessed by two individuals. If the Principal Signing will be Notarized, the Notary Public should be directed to the section title “Option 1: Notary Public.”If the Principal Signing will be verified by two Witnesses, each Witness should direct his or her attention to the section labeled “Option 2: Two Witnesses” where each Witness will have one area to tend to (“Witness One” and “Witness Two.” Each Witness must physically supply the Execution Date and Name of the Principal in the first statement of his or her respective section. Once done, the appropriate Witness must sign the Witness Signature line and document his or her Address, just below the statement.The Health Care Agent will also have to participate here. He or she should read the passage titled “Acceptance Of Appointment Of Power Of Attorney” then, Sign and Date the blank lines supplied at the end of it.

Related Forms

Durable Financial Power of Attorney

Download: Adobe PDF, MS Word, OpenDocument




Last Will and Testament

Download: Adobe PDF, MS Word, OpenDocument