ADVANCE DIRECTIVE FOR HEALTH CARE

I, [NAME], hereby give these advance instructions on how I want to be treated by my doctors and other health care providers when I can no longer make those treatment decisions myself. 

Part I Agent: I want the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my agent must follow my instructions below: 

Name: [NAME]

Relation: [RELATION]

Home Phone: [PHONE NUMBER]

Work Phone: [PHONE NUMBER]

Address: [ADDRESS, STREET, CITY, STATE, ZIP CODE]

Mobile Phone: [PHONE NUMBER]

Alternate Agent: If the person named above is unable or unwilling to make health care decisions for me, I appoint as alternate the following person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my agent must follow my instructions below: 

Name: [NAME]

Relation: [RELATION]

Home Phone: [PHONE NUMBER]

Work Phone: [PHONE NUMBER]

Address: [ADDRESS, STREET, CITY, STATE, ZIP CODE]

Mobile Phone: [PHONE NUMBER]

My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA. 

When Effective (mark one):
☐ – I give my agent permission to make health care decisions for me at any time, even if I have capacity to make decisions for myself.
☐ – I do not give such permission (this form applies only when I no longer have capacity). 

Signature: ______________________________________________________

Date: [DAY] day of [MONTH], 20[XX]

Signature of witness number 1: ________________________________________

Date: [DAY] day of [MONTH], 20[XX]

Signature of witness number 2: ________________________________________

Date: [DAY] day of [MONTH], 20[XX]