Durable Power of Attorney for Health Care and Living Will

VA FORM
10-0137
Page 1 of 7
JUL 2015
This advance directive form is an official document where you can write down your preferences for your
health care. If someday you can’t make health care decisions for yourself anymore, this advance directive
can help guide the people who will make decisions for you.
You can use this form to:
l
Name specific people to make health care decisions for you
l
Describe your preferences for how you want to be treated
l
Describe your preferences for medical care, mental health care, long-term care, or other types of health
care
When you complete this form, it’s important that you also talk to your doctor, family, and other loved ones
who may help to decide about your care. You should explain what you meant when you filled out the form.
A health care professional can help you with this form and can answer any questions that you have. If you
need more space for any part of the form, you may attach extra pages. Be sure to initial and date every page
that you attach.
VA ADVANCE DIRECTIVE
DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
OMB Approval Number 2900-0556
Estimated Burden Avg: 30 minutes
Expiration Date: 10/31/2017
PART I: PERSONAL INFORMATION
NAME (Last, First, Middle): LAST FOUR DIGITS OF SSN:
STREET ADDRESS:
CITY, STATE, ZIP:
HOME PHONE WITH AREA CODE: WORK PHONE WITH AREA CODE: MOBILE PHONE WITH AREA CODE:
Privacy Act Information and Paperwork Reduction Act Notice
The information requested on this form is solicited under the authority of 38 C.F.R. §17.32. It is being collected to document
your preferences for your health care in the event that you can’t speak for yourself anymore. The information you provide
may be disclosed outside the VA as permitted by law. Possible disclosures include those that are described in the “routine
uses” identified in the VA system of records 24VA19, Patient Medical Record-VA, published in the Federal Register in
accordance with the Privacy Act of 1974. This is also available in the Compilation of Privacy Act Issuances at
health care providers may not understand your preferences as well. If you don’t fill out this form, there won’t be any effect on
the benefits you are entitled to receive. The Paperwork Reduction Act of 1995 requires us to let you know that this
information collection follows the clearance requirements of section 3507 of this Act. We estimate that it will take you about
30 minutes to fill out this form, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the information you write down. A Federal agency may not
conduct or sponsor, and a person is not required to respond to a collection of information, unless it displays a current valid
OMB control number. The OMB Control No. for this information collection is 2900-0556.
http://www.gpoaccess.gov/privacyact/index.html. You may choose to fill out this form or not. But without this information, VA
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