YOU DO NOT HAVE TO FILL OUT AND SIGN THIS FORM
PART A: IMPORTANT INFORMATION ABOUT THIS ADVANCE DIRECTIVE
This is an important legal document. It can control critical decisions about your health care. Before
signing, consider these important facts:
Facts About PART B (Appointing a Health Care Representative)
You have the right to name a person to direct your health care when you cannot do so. This person is
called your “health care representative.” You can do this by using PART B of this form. Your
representative must accept on PART E of this form.
In this document, you can write any restrictions you want on how your representative will make
decisions for you. Your representative must follow your desires as stated in this document or otherwise
made known. If your desires are unknown, your representative must try to act in your best interest.
Your representative can resign at any time.
Facts About PART C (Giving Health Care Instruction)
You also have the right to give instructions for health care providers to follow if you become unable to
direct your care. You can do this by using PART C of this form.
Facts About Completing This Form
This form is valid only if you sign it voluntarily and when you are of sound mind. If you do not want an
advance directive, you do not have to sign this form.
Unless you have limited the duration of this directive, it will not expire. If you have set an expiration
date, and you become unable to direct your health care before that date, this advance directive will not
expire until you are able to make those decisions again.
You may revoke this document at any time. To do so, notify your representative and your health care
provider of the revocation.
Despite this document, you have the right to decide your own health care as long as you are able to do
If there is anything in this document that you do not understand, ask a lawyer to explain it to you.
You may sign PART B, PART C, or both parts. You may cross out words that don’t express your