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Name (Last, First, Middle):
VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)
LAST FOUR DIGITS OF SSN:
Place your initials in the box next to your choice. Choose only one.
Relationship to Me:
A - HEALTH CARE AGENT
PART II: DURABLE POWER OF ATTORNEY FOR HEALTH CARE
I don't wish to appoint a Health Care Agent right now.
(Skip this section and go to Part III, Living Will.)
I appoint the person named below to make decisions about my health care if I can't decide for myself
This section of the advance directive form is called a Durable Power of Attorney for Health Care. It lets you
appoint a specific person to make health care decisions for you in case you can’t make decisions for
yourself anymore. This person will be called your Health Care Agent.
Your Health Care Agent should be someone:
Who knows you well
l Who is familiar with your values and beliefs
If you get too sick to make decisions for yourself, your Health Care Agent will have the authority to make all
health care decisions for you. This includes decisions to admit and discharge you from any hospital or other
health care institution. Your Health Care Agent can also decide to start or stop any type of health care
treatment. He or she can access your personal health information, including your medical records.
NOTE: Information about whether you have been tested for HIV or treated for AIDS, sickle cell anemia,
substance abuse or alcoholism will only be shared with your Health Care Agent under very limited
circumstances. If you wish to give general permission for VA to share this information with your Health Care
Agent, you will need to give special written consent by completing VA Form 10-5345. You can get VA Form
10-5345 from your VA health care provider or you can get it using a computer from this website
City, State, Zip:
Work Phone with Area Code:Home Phone with Area Code: Mobile Phone with Area Code: