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OTHER NAMES Living Will Advance Healthcare Directive Medical Directive Advance Medical Directive Advance Health Care Directive

What is an Advance Directive?

An Advance Directive is a legal document that sets forth your preferences related to health care, such as your refusal of or request for medical treatment, or the selection of a chosen healthcare agent. 
 
The person making an Advance Directive is known as the "principal," and the person or organization obtaining authority to carry out the principal's wishes is called the "agent." Each Advance Healthcare Directive from Rocket Lawyer can be modified for your specific scenario. This official legal document provides a record of your decisions to healthcare facilities, and it will certify that your selected agent has been authorized to make choices for you when you are not able.

When to use an Advance Directive:

  • You're making sure your loved ones aren't put in the position of making important end-of-life healthcare decisions for you.
  • You're about to draft a complete estate plan, and want to make sure life-sustaining treatments are covered.

Sample Advance Directive

The terms in your document will update based on the information you provide

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ADVANCE HEALTH CARE DIRECTIVE

(California Probate Code Section 4701)

 

EXPLANATION

 

You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.

 

Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. (Your agent may not be an operator or employee of a community care facility or a residential care facility where you are receiving care, or your supervising health care provider or employee of the health care institution where you are receiving care, unless your agent is related to you or is a coworker.

 

Unless the form you sign limits the authority of your agent, your agent may make all health care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to:

 

(a) Consent or refuse to consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition.

(b) Select or discharge health care providers and institutions.

(c) Approve or disapprove diagnostic tests, surgical procedures, and programs of medication.

(d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation.

(e) Make anatomical gifts, authorize an autopsy, and direct disposition of remains.

 

Part 2 of this form lets you give specific instructions about any aspect of your health care, whether or not you appoint an agent. Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to keep you alive, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out Part 2 of this form.

 

Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death.

 

Part 4 of this form lets you give the authority to your agent to authorize autopsy and disposition of your remains.

 

Part 5 of this form lets you give the authority to your agent to signed forms under HIPAA that refers to the release of your medical records.

 

Part 6 of this form lets you designate a physician to have primary responsibility for your health care. After completing this form, sign and date the form at the end. The form must be signed by two qualified witnesses or acknowledged before a notary public. Give a copy of the signed and completed form to your physician, to any other health care provider you may have, to any health care institution at which you are receiving care and to any health care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility.

 

You have the right to revoke this advance health care directive or replace this form at any time.

 

 

PART 1

POWER OF ATTORNEY FOR HEALTH CARE

 

. DESIGNATION OF AGENT. I, , residing at , , , do hereby designate the following individual as my agent to make health care decisions for me:

Agent:

Name:

Address:

  ,

Phone: Home: Work:

 

. AGENT'S AUTHORITY. My agent is authorized to make all health care decisions for me, including decisions to provide, withhold or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive

 

. WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE. My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions

 

. AGENT'S OBLIGATION. My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

 

 

PART 2

INSTRUCTIONS FOR HEALTH CARE

 

If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out this part of the form.

 

. END-OF-LIFE DECISIONS. I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with the choice I have initialed below:

 

 

. ARTIFICIAL NUTRITION AND HYDRATION. Artificial nutrition and hydration must be provided, withheld or withdrawn in accordance with the choice I have made in paragraph

 

. RELIEF FROM PAIN.

 

 

PART 3

DONATION OF ORGANS AT DEATH

 

 

 

PART 4

AUTOPSY AND DISPOSITION ON REMAINS

 

. Upon my death, I give the authority to my agent to authorize an autopsy make determinations for disposition of my remains.

 

 

PART 5

AUTHORIZATION TO SIGN FORMS UNDER HIPAA

 

. With this document I authorize my agent to sign all forms required under HIPAA that refer but are not limited to the release of my medical records.

 

 

PART 6

PRIMARY PHYSICIAN

 

. I designate the following physician as my primary physician:

Physician:

Name:

Address:

  ,

Phone:

 

If a primary physician is not selected under part 6, then I request that the rules of California Medical Association be applied for the identification of my primary physician.

 

 

PART 7

 

. EFFECT OF COPY. A copy of this form has the same effect as the original.

 

. SIGNATURE.

 

Declarant Signature: _______________________________________

Name:

Address:

  ,

Date: _____________________

 

NOTICE: SPECIAL RULES APPLY IF YOU ARE A RESIDENT OF A SKILLED NURSING FACILITY. IF YOU RESIDE IN SUCH A FACILITY, THIS DOCUMENT MUST BE SIGNED BY A PATIENT ADVOCATE OR OMBUDSMAN. IF YOUR DOCUMENT IS BEING WITNESSED BY TWO WITNESSES, ONE OF THOSE WITNESSES MUST BE THE ADVOCATE OR OMBUDSMAN WHO SIGNS ALL WITNESS STATEMENTS. IF YOUR DOCUMENT IS BEING NOTARIZED, THE ADVOCATE OR OMBUDSMAN MUST SIGN THE SPECIAL WITNESS REQUIREMENT SECTION.

 

. STATEMENT OF WITNESSES: [If you are a resident in a skilled nursing facility, a patient advocate or ombudsman must sign this statement as one of your two witnesses.]

 

I declare under penalty of perjury under the laws of California:

(1) that the individual who signed or acknowledged this advance health care directive is personally known to me, or that the individual's identity was proven to me by convincing evidence,

(2) that the individual signed or acknowledged this advance directive in my presence,

(3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence,

(4) that I am not a person appointed as agent by this advance directive,

(5) that I am not the individual's health care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly, and

(6) that I am an adult.

 

 

Witness Signature:  ________________________________________

 

 

Date: _________________________

 

 

 

Witness Signature:  ________________________________________

 

 

Date: _________________________

 

 

. ADDITIONAL STATEMENT OF WITNESSES. At least one of the above witnesses must also sign the following declaration. [If you are a resident in a skilled nursing facility, the patient advocate or ombudsman must sign this statement.]

 

I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of law.

 

 

 

Witness Signature:  ________________________________________

 

Name: ________________________________

Address: ________________________________

  ________________________________

  ________________________________

 

Date: _________________________

 

PART 8

 

. SPECIAL WITNESS REQUIREMENT.

 

The following statement is required only if you are a patient in a skilled nursing facility - a health care facility that provides the following basic services: skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. The patient advocate or ombudsman must sign the following statement:

 

STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN: I declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and that I am serving as a witness as required by Section 4675 of the Probate Code.

 

I further declare:

(1) that the individual who signed or acknowledged this advance health care directive is personally known to me, or that the individual's identity was proven to me by convincing evidence,

(2) that the individual signed or acknowledged this advance directive in my presence,

(3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence,

(4) that I am not a person appointed as agent by this advance directive,

(5) that I am not the individual's health care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly,

(6) that I am an adult, and

(7) that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of law.

 

 

 

Witness Signature:  ________________________________________

 

Name: ______________________________

Address: ______________________________

City, State, Zip: ______________________________

 

 

When you complete this form, you are advised that you may not regard this form as completed with the assistance of an attorney.

 

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Advance Directive FAQs

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  • How do I write an Advance Directive online for free?

    It is very easy to outline your medical wishes using a free Advance Directive template from Rocket Lawyer:

    1. Make your Advance Directive - Provide a few general details, and we will do the rest
    2. Send and share it - Look over it with your healthcare agent(s) or ask a legal question
    3. Sign and make it legal - Mandatory or not, witnesses and notarization are recommended

    This route, in many cases, will be notably less time-consuming than hiring a conventional law firm. If needed, you may fill out an Advance Directive on behalf of an elderly parent, a spouse, or another family member, and then have that person sign it once you've drafted it. Please remember that for this document to be valid, the principal must be an adult who is mentally competent at the time of signing. In the event that the principal has already been declared incompetent, a court-appointed conservatorship generally will be required. When facing such a situation, it is important to speak to a lawyer .

  • What does an Advance Directive cover?

    Unless limited, an Advance Directive gives your agent very broad authority to make all healthcare decisions for you including:

    • Consenting or refusing to consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition
    • Selecting or discharging healthcare providers or institutions
    • Approving or disapproving diagnostic tests, surgical procedures and programs of medication
    • Directing the provision, withholding or withdrawal of artificial nutrition and hydration and all other forms of healthcare, including pulmonary resuscitation
    • Making anatomical gifts, authorizing an autopsy and directing disposition of remains.
  • Can I limit or specify my agent's authority?

    In your Advance Directive you may limit your agent's authority to make decisions for you by stating your wishes.

    If you do not want your life prolonged under all circumstances, our Advance Directive helps guide you in making this very important decision by giving you some choices about specific situations in which you may not want your life to be prolonged, such as:

    • If you have an irreversible condition and death will occur soon
    • If you are permanently unconscious
    • If the risks of treatment outweigh the benefits

    If you do not want to receive food and fluids artificially regardless of your condition, you may specify this limitation. If you wish, you may also state under what circumstances you do not want treatment to alleviate pain or discomfort.Finally, you may can convey your instructions regarding organ or tissue donations, including not wanting donation for any purposes or defining the purposes for which you would want your organs or tissues to be donated.

  • When does an Advance Directive come into effect?

    You may choose to have your Advance Directive become effective immediately (even if you are still capable of making your own healthcare decisions) or to have your Advance Directive only become effective when you are incapable of making healthcare decisions for yourself (The latter is the more common scenario.)

  • Why should I have an Advance Directive?

    Every person over 18 years old should have an Advance Healthcare Directive (both a Healthcare Power of Attorney and a Living Will) in place. While it's difficult to think about, there will likely come a time when you cannot make medical decisions on your own. Here are a few common situations where it might be useful to make or update your Advance Directive:

    • You are preparing to move into an adult care facility
    • You've been diagnosed with a terminal condition
    • You are aging or dealing with ongoing health issue
    • You are undergoing an in-patient procedure requiring anesthesia

    Whether your Advance Directive has been made as a result of a change in your health or as part of a forward-looking plan, notarization and/or witnesses are strongly recommended for protecting this document and your agent if someone challenges their privileges. Please note that this document is not valid during pregnancy in all states.

  • Do I need an attorney for my Advance Directive?

    Making an Advance Directive is usually simple; however, you or your agent(s) could have legal questions. Locating someone to review your document could take a lot of time if you do it by yourself. Another approach to consider is to request help from Rocket Lawyer attorney services. Premium members can ask for feedback from an experienced lawyer or ask additional legal questions. As always, you can Live Confidently® with Rocket Lawyer by your side.

  • What would I normally need to pay for an attorney to help me make an Advance Directive?

    The cost of finding and hiring a legal provider to produce an Advance Directive could total between $200 and $1,000. Rocket Lawyer isn't a run-of-the-mill Advance Directive template website. With our service, anyone under a Rocket Lawyer membership has access to up to 40% in savings when hiring an attorney from our network.

  • Am I required to do anything else after I have drafted an Advance Directive?

    After completing an Advance Directive with Rocket Lawyer, you will have the ability to open it wherever and whenever you choose. You also can try any or all of these actions with your document: editing it, printing it, and/or signing it. Attached to your Advance Healthcare Directive, you will find a set of instructions on what comes next after the document is finished. Your agent(s), care providers, and other impacted parties should receive copies of your final document.

  • Does an Advance Directive need to be notarized or witnessed?

    The requirements and restrictions governing Advance Directives are different in each state; however, it is strongly recommended to have your Advance Directive signed by at least one witness and/or notarized to emphasize its legitimacy. As a basic principle, witnesses will need to be at least 18 years old, and none should simultaneously be your healthcare agent.

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