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Fillable Form Advance Health Care Directive Letter

An advance health care directive letter is a document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions.

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What is an Advance Health Care Directive form?

An Advance Health Directive is a legal document that states what you want in regard to your future health care and which directions, procedures, and precautions you are opting for in various medical conditions.

You may dictate that your directive be put into action at any time when you are unable to decide for yourself, or you may want it to be applicable only if you are in critical condition or suffering from a terminal illness.

It comes into effect only if you are unable to make your own decisions. There may come a time wherein you are unable to verbalize or think with a sound mind and, upon completion of this form, you can dictate your medical treatment, wishes, and process before that time comes.

This form deals with your future health care.

Why should I file an Advance Health Care Directive form?

It is in the legal and lawful right of every responsible adult over the age of eighteen (18) to either accept or refuse any recommended health care. This is something feasible for healthy and well individuals to dictate and decide on. On the other hand, individuals suffering from critical conditions, severe illnesses, or terminal illnesses are often unconscious during such critical moments of decision-making and it renders them unable to speak their wishes.

By completing the Advance Health Care Directive form, you may dictate your wishes and your opted medical direction when such a time of illness comes.

Who should file an Advance Health Care Directive Form?

Any legal adult over the age of eighteen (18) and has an intellectual capacity mature enough to understand the implications of life-or-death situations can file for an Advance Health Care Directive. Moreover, the legal individual must be able to understand the nature of their decisions and foresee the effect their decisions can have.

Other points to consider when deciding if you are at a capacity to file for an Advance Health Care Directive:

  • You understand the nature and consequences of your health care decisions.
  • You understand the nature and effect of the directive.
  • You understand that you are freely and voluntarily making these decisions.
  • You can communicate your decisions in some way.

It should be noted that there are three (3) people involved in the completion of the Advance Health Care Directive form:

  1. You
  2. Patient Advocate Authority (also referred to as the ‘agent’ or ‘attorney-in-fact’.)
  3. Second (2nd) Patient Advocate Authority (this is in case the first choice cannot serve, is not willing, able, or reasonably available to make health care decisions for you.)

It should also be noted that your Advance Health Care Directive should be witnessed by two (2) legal adults over the age of eighteen (18) and are able to vouch and certify that you are of sound mind and mature mental capacity or signed before a notary public. Depending on your state, though, you may need both witnesses and notarization.

Depending on your state, it should be noted that a witness cannot be:

  • a health care provider
  • an employee of a healthcare provider or health care facility
  • your agent designated in the Advance Health Care Directive

At least one of the witnesses must be someone who is not a relative to you and is not entitled to any part of your estate or Last Will.

When to make an Advance Health Care Directive form?

Now is the best time to make an Advance Health Care Directive, when you are currently clear of any illness or still functioning at a healthy capacity. However, it is crucial to make one if:

  • You are about to be admitted to a hospital.
  • Your medical condition/illness will most likely end up affecting your decision-making process.
  • Your illness is a chronic medical condition that could impact your health drastically (heart disease, kidney disease, etc.)

It is recommended that you reassess your Advance Health Care Directive every few years that pass or when any “Five (5) Ds” take place. The Five (5) Ds are:

  1. Decade - when a new decade (10 years) of your life begins.
  2. Death - when there is death of a loved one.
  3. Divorce - when you and your spouse separate.
  4. Diagnosis - when your health condition is diagnosed with a serious sickness/illness/disease.
  5. Decline - when the state of your health drastically diminishes and impacts your lifestyle significantly.

How to accomplish the Advance Health Care Directive form?

Since the Advance Health Care Directive form involve specific instructions regarding medical treatments, procedures, and processes that may lead to the difference between life or death, it is important to consider first these points before choosing to accomplish the form:

  • Does your illness have no cure or do you have little to no chance of recovering from it?
  • Are the damages done by the illness irreversible?
  • Are life-prolonging measures and tools like tube-feeding, CPR, ventilators, intravenous fluids okay with you?

It is important to consider and highlight the quality of life that would be acceptable to you and would best suit your medical condition.

The Advance Health Care Directive form is split into five (5) parts that require filling out, namely:

  1. Advance Health Care Directive Form
  2. Appointment of Patient Advocate
  3. Other Patient Advocate Authority
  4. Health Care Wishes (Living Will)
  5. Making My Directive Legal

For the Advance Health Care Directive form section, please affix your full name on the line provided to confirm that you are of sound mind and are freely and voluntarily appointing a patient advocate (agent) to aid you in making decisions about your medical treatments in the future in case you are not able to communicate or relay your wishes yourself.

For the Appointment of Patient Advocate section, please affix your chosen agent’s full name, your relationship to them, their current residential address, and contact number on the lines provided for each.

  • Please make sure to go through and review the ‘Patient Advocate Authority’ located below the ‘Appointment of Patient Advocate’ for further details of the power you are giving to your chosen agent come your inability to communicate your wishes.

For the Other Patient Advocate Authority section, please go through and review thoroughly the additional powers you are willing to give to your appointed agent. Once reviewed, please initial ‘Yes’ on the statements you agree to let your agent have power to.

  • You are also given writing space below to print/type down any limit or expansion of the power of your agent.

For the Health Care Wishes (Living Will) section, please choose only one box of instructions that you wish to have followed by your appointed agent. Choose the box by marking it through.

  • If you selected the option that states you choose not to receive care for the purpose of prolonging life, you must select between additional instructions labeled option a or b.
    • If you choose option A, you will have to choose between five (5) additional options to explain why your appointed agent has no power limit.
  • You are also given writing space below to print/type down any additional instructions about your health care wishes.
  • Please make sure to go through and review ‘Revoking or Changing a Directive’ for instructions on how to void or change some conditions written in the Advance Health Care Directive form.

For the Making My Directive Legal section, please affix your full name, address, and signature along with the date of when you signed the form to the lines provided for each.

Your witness should affix their full name, address, and signature along with the date of when they signed the form to the lines provided for each as well.

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