A Utah advance directive is a form that allows someone to designate someone else to make healthcare decisions for them when they cannot make decisions or speak for themselves. The advance directive also allows the principal to record their wishes about healthcare in writing. The form becomes extremely useful in situations of mental incapacitation or illness.
Statutory Form
- Statute: § 75-2a-117
- Download: Adobe PDF
Street Address: [STREET ADDRESS]
City, State, Zip Code: [CITY, STATE, ZIP CODE]
Telephone: [PHONE NUMBER]
Cell Phone: [PHONE NUMBER]
Birth date: [DAY] day of [MONTH], [YEAR]
[INITIALS] I do not want to choose an agent.
Street Address: [STREET ADDRESS]
City, State, Zip Code: [ADDRESS, CITY, STATE, ZIP CODE]
Home Phone: [PHONE NUMBER] Cell Phone: [PHONE NUMBER] Work Phone: [PHONE NUMBER]
- Consent to, refuse, or withdraw any health care. This may include care to prolong my life such as food and fluids by tube, use of antibiotics, CPR (cardiopulmonary resuscitation), and dialysis, and mental health care, such as convulsive therapy and psychoactive medications. This authority is subject to any limits in paragraph F of Part I or in Part II of this directive.
- Hire and fire health care providers.
- Ask questions and get answers from health care providers.
- Consent to admission or transfer to a health care provider or health care facility, including a mental health facility, subject to any limits in paragraphs E and F of Part I.
- Get copies of my medical records.
- Ask for consultations or second opinions.
My agent has the powers below ONLY IF I initial the “yes” option that precedes the statement. I authorize my agent to:
- YES [INITIALS] NO [INITIALS] Get copies of my medical records at any time, even when I can speak for myself.
- YES [INITIALS] NO [INITIALS] Admit me to a licensed health care facility, such as a hospital, nursing home, assisted living, or other facility for long-term placement other than convalescent or recuperative care.
- YES [INITIALS] NO [INITIALS] I, being of sound mind and not acting under duress, fraud, or other undue influence, do hereby nominate my agent, or if my agent is unable or unwilling to serve, I hereby nominate my alternate agent, to serve as my guardian in the event that, after the date of this instrument, I become incapacitated.
[DAY] day of [MONTH], 20[XX]
Date
____________________________________
Signature
I have witnessed the signing of this directive, I am 18 years of age or older, and I am not:
1. related to the declarant by blood or marriage;
2. entitled to any portion of the declarant’s estate according to the laws of intestate succession of any state or jurisdiction or under any will or codicil of the declarant;
3. a beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transfer on death deed that is held, owned, made, or established by, or on behalf of, the declarant;
4. entitled to benefit financially upon the death of the declarant;
5. entitled to a right to, or interest in, real or personal property upon the death of the declarant;
6. directly financially responsible for the declarant’s medical care;
7. a health care provider who is providing care to the declarant or an administrator at a health care facility in which the declarant is receiving care; or
8. the appointed agent or alternate agent.
____________________________________
Signature of Witness
Adobe PDF