Advance Health Care Directive of ________________________________________________________ Page 2
You should read this form carefully before filling it in. You should fill it in completely.
If there are health care decisions you do not want to make, you should strike the wording
of that decision rather than leave it blank. You may not change the qualifications for
witnesses or agents, even if you cross out t he wording . You should write legibly.
After you have filled out the form completely, you should sign the form before a
notary public. Although signing before a notary public is not legally required, it is
advisable. It is advisable because the notary, as well as your witnesses, can testify as to
your competence when you sign the directive, if your competence becomes an issue.
Notaries, who are registered with the State, are often easier to locate later than
You should retain your original Advance Health care Directive, and give copies to
your doctor, agent, spouse, f amily member s, and close friends, if you desire. You should
explain to each person who receives a copy of your health care directive what choices
you m ade on t he f orm , and why. T his will help if, while you lack compet ence, t here ar ises
a need to make a health care decision that is not explicitly set forth on your advance
health car e dir ective f o r m .
This form does not contain all of the types of health care decisions you are legally
entitled to make. For example, the form does not give you the opportunity to nominate a
guardian, in the event you become incompetent and need one. Also, the form does not
give you the opportunity to designate a primary care physician, or another person, to
certify that you lack the capacity to make your own decisions on health care. Finally, the
form does not include a provision that accommodates a person’s religious or moral
beliefs. If you would like to exercise these options, you should talk to an attorney. If
anything on the form conflicts with your relig ious beliefs, you should contact your cler gy.
PART I. INSTRUCTIONS FOR HEALTH CARE DECISIONS
If you are an adult who is mentally competent, you have the right to accept or refuse
medical or surgical treatment, if such refusal is not contrary to existing public health laws. You
may give advance instructions for medical or surgical treatment that you want or do not want.
These instructions will become effective if you lose the capacity to accept or refuse medical or
surgical treatment. You may limit your instructions to take effect only if you are in a specified
medical condition. If you give an instruction that you do not want your life prolonged, that
instruction will only take effect if you are in a “qualifying condition.” A “qualifying condition” is
either a t er m inal condit ion or per m anent unconsciousness.
If you want t o give instruct ions to accept or r efuse medical or sur gical t r eatment, you
should fill in t he spaces on t he following page. You m ay cross out any wording you do not