Advance Health Care Directive Form Instructions
You have the right to give instructions about your own health care.
You also have the right to name someone else to make health care decisions for you.
The Advance Health Care Directive form lets you do one or both of these things. It also lets you write down
your wishes about donation of organs and the selection of your primary physician. If you use the form, you may
complete or change any part of it or all of it. You are free to use a different form.
Part 1: Power of Attorney
Part 1 lets you:
•	 name another person as agent to make health
care decisions for you if you are unable to make
your own decisions. You can also have your
agent make decisions for you right away, even if
you are still able to make your own decisions.
•	 also name an alternate agent to act for you if
your first choice is not willing, able or reasonably
available to make decisions for you.
Your agent may not be:
•	 an operator or employee of a community care
facility or a residential care facility where you are
•	 your supervising health care provider (the doctor
managing your care)
•	 an employee of the health care institution where
you are receiving care, unless your agent is
related to you or is a coworker.
Your agent may make all health care decisions for
you, unless you limit the authority of your agent.
You do not need to limit the authority of your agent.
If you want to limit the authority of your agent the
form includes a place where you can limit the
authority of your agent.
If you choose not to limit the authority of your
agent, your agent will have the right to:
•	 Consent or refuse consent to any care, treatment,
service, or procedure to maintain, diagnose, or
otherwise affect a physical or mental condition.
•	 Choose or discharge health care providers (i.e.
choose a doctor for you) and institutions.
•	 Agree or disagree to diagnostic tests, surgical
procedures, and medication plans.
•	 Agree or disagree wit