1. Home »
  2. Power of Attorney »
  3. Advance Directive

Advance Directive Forms

Fill Now Click to fill, edit and sign this form now!

An advance directive allows a person to plan their end-of-life treatment and nominate an agent responsible for carrying out their medical wishes. It goes into effect when the principal (the one completing the form) enters into an incapacitated medical state. Medical incapacitation refers to an inability to communicate effectively due to reduced cognitive function and is determined by a licensed physician.

An Advance Directive is a combination of both a medical power of attorney and a living will.

By State

Contents

What is an Advance Directive?

An advance directive allows a patient to make many medical decisions for themselves in advance in case they cannot speak for themselves or make important decisions (a state referred to as being “incapacitated”). This is common before someone undergoes surgery or if they starting showing signs of onset of dementia or other mind-altering conditions.

In most states, there are five (5) parts to an advance directive:

How to Get an Advance Directive

The five (5) steps below provide instructions on how a person of sound mind can obtain an advance directive in their state.

Step 1 – Qualify

Any person residing in the United States is qualified to create an advance directive, except those that fall under any of the following categories:

  • Under eighteen (18) years of age
  • Incapacitated
  • Incarcerated (in jail)
  • Outside of the country and not able to return

Conservatorship / Guardianship – If a person is already incapacitated, a spouse or family member may need to seek an attorney so they can apply for conservatorship or guardianship. This is can be filed immediately to make medical and financial decisions for someone else.

Step 2 – Make Decisions About Your Health Care

For the living will section, the principal will need to decide whether or not to withhold end-of-life treatment options such as breathing assistance, artificial nutrition and hydration, and prolonged relief from pain.

In addition, the principal will be able to decide where their organs will go after their death (i.e., donation options) and select their preferred primary care physician.

Step 3 – Choose an Agent

For the medical power of attorney section, the principal will need to decide who to select as their agent (also known as a “proxy” or “attorney-in-fact”). In most cases, the agent selected is the spouse, a family member, or a close friend.

An advance directive does not usually allow co-agents, but it does allow alternate agents in the event the first (1st) selected agent is unable to serve.

Step 4 – Sign the Form

An advance directive is not complete until it has been executed in accordance with the signing requirements of the principal’s state of residence. This often involves the principal and their agents signing the document in the presence of two (2) witnesses, a notary public, or both.

In the case of using witnesses, most states require that a witness cannot be the following individuals:

  • A family member;
  • A beneficiary of the principal’s Last Will and Testament;
  • A health care professional; or
  • A person under the age of 18.

Step 5 – Make Copies and Distribute

After the advance directive has been properly executed, it should be distributed to all healthcare agencies of the principal including their primary care physician. Most importantly, the agents of the principal should all receive copies so they can effectively communicate the principal’s wishes in the unfortunate circumstance they can no longer speak for themselves.

Step 6 – Registry Filing (optional)

This step isn’t required, but some states have a registry where the principal can record the advance directive to prove its existence. There are national registries that may be used, such as the U.S. Living Will Registry and DocuBank, that help to ensure the form is safely stored.

Filing an advance directive in an official registry helps to safeguard against any family member or third (3rd) party disagreeing with the principal’s intentions that are outlined in the form.


Advance Directive: Laws

The Uniform Health-Care Decisions Act is a federally recognized law that has been adopted in seven (7) states (Alaska, Delaware, Hawaii, Maine, Mississippi, New Mexico, and Wyoming). Each state has its own laws pertaining to the execution and application of advance directives.

STATE SIGNING REQUIREMENTS STATUTE
Alabama 2+ Witnesses § 22-8A-4(c)(4)
Alaska 2 Witnesses OR Notary § 13.52.010(b)
Arizona 1 Witness OR Notary § 36-3282(5)
Arkansas 2 Witnesses § 20-6-103(c)(1)
California 2 Witnesses OR Notary § 4673(3)
Colorado 2 Witnesses § 15-18-106(1)
Connecticut 2 Witnesses § 19a-575
Delaware 2+ Witnesses § 2503(b)(1)(d)
Florida 2 Witnesses § 765.202(1)
Georgia 2 Witnesses § 31-32-5(c)
Hawaii 2 Witnesses OR Notary § 327E-3
Idaho N/A No statute
Illinois 2 Witnesses 755 ILCS 35/3
Indiana 2 Witnesses § 16-36-4-8(b)(5)
Iowa 2 Witnesses § 144A.3(2)(a)
Kansas 2+ Witnesses § 65-28,103(a)
Kentucky 2 Witnesses OR Notary § 311.625
Louisiana 2 Witnesses RS 40:1151.4(A)(2)(b)
Maine 2 Witnesses § 5-803(2)
Maryland 2 Witnesses § 5–602(c)(1)
Massachusetts N/A No statute
Michigan N/A No statute
Minnesota 2 Witnesses OR Notary § 145B.03(2)(a)
Mississippi 2 Witnesses OR Notary § 41-41-205(2)(a)
Missouri 2 Witnesses § 459.015(4)
Montana 2 Witnesses § 50-9-103(1)
Nebraska 2 Witnesses OR Notary § 20-404(1)
Nevada 2 Witnesses NRS 449A.618
New Hampshire 2 Witnesses OR Notary § 137-J:14
New Jersey 2 Witnesses OR Notary § 26:2H-56
New Mexico Principal’s Signature § 24-7A-2(B)
New York N/A No statute
North Carolina 2 Witnesses § 90-321(c)(3)
North Dakota 2 Witnesses OR Notary 23-06.5-05(2)
Ohio 2 Witnesses OR Notary 2107.03
Oklahoma 2 Witnesses § 63 3101.4(A)
Oregon 2 Witnesses OR Notary 127.515(2)
Pennsylvania 2 Witnesses § 54-5442(b)(2)
Rhode Island 2 Witnesses § 23-4.11-3(a)
South Carolina 2 Witnesses § 44-77-40(2)
South Dakota 2 Witnesses § 34-12D-2
Tennessee 2 Witnesses OR Notary § 32-11-104(a)
Texas 2 Witnesses § 166.032(b)
Utah 1 Witness § 75-2a-107(c)
Vermont 2+ Witnesses § 9703(b)
Virginia 2 Witnesses § 54.1-2983
Washington 2 Witnesses OR Notary RCW 70.122.030(1)
West Virginia 2+ Witnesses § 16-30-4(a)(4)
Wisconsin 2 Witnesses § 154.03(1)
Wyoming 2+ Witnesses OR Notary § 35-22-403(b)

Sample

Download: PDF (Blank) | PDF (Sample Data)

ADVANCE DIRECTIVE

This form was completed and signed on [MM/DD/YYYY].

1. HEALTH CARE DIRECTIVE (LIVING WILL).

I, [PRINCIPAL NAME], with a street address of [PRINCIPAL STREET], City of [PRINCIPAL CITY], County of [PRINCIPAL COUNTY], State of [PRINCIPAL STATE], with the last four (4) digits of my social security number (SSN) being XXXX – XX – [XXXX] (Hereinafter may be referred to as the ‘Principal’) desire to advise my doctors and medical providers of my wishes for my health care in the event I am not able to communicate my wishes.

a. Life Support

I desire that my doctor make a concerted effort to return me to an acceptable quality of life using the available treatments and therapies. However, if my quality of life becomes unacceptable, as I have defined below, and my doctors have determined that my condition will not improve (is irreversible), I direct that all treatments that extend my life be withdrawn.

Unacceptable quality of life means (initial and check all that apply):

[INITIAL] ☐ – Chronic coma or persistent vegetative state
[INITIAL] ☐ – no longer able to communicate my needs
[INITIAL] ☐ – no longer able to recognize family or friends
[INITIAL] ☐ – total dependence on others for daily care
[INITIAL] ☐ – Other: [OPTIONAL – OTHER UNACCEPTABLE QUALITY OF LIFE].

Initial and check only one:

[INITIALS] ☐ – Even if I have the quality of life described above, I still wish to be treated with food and water by tube or intravenously (IV).
[INITIALS] ☐ – If I have the quality of life described above, I do NOT wish to be treated with food and water by tube or intravenously (IV).

b. Certain Life-Sustaining Treatment

Some people do not wish to have certain life-sustaining treatments under any circumstance, even if recovery is a possibility. Check treatments below, if any, that you do not wish to have under any circumstances:

[INITIAL] ☐ – Cardiopulmonary Resuscitation (CPR)
[INITIAL] ☐ – Ventilation (breathing machine)
[INITIAL] ☐ – Feeding tube
[INITIAL] ☐ – Dialysis
[INITIAL] ☐ – Other: [OPTIONAL – OTHER UNWANTED LIFE-SUSTAINING TREATMENT.

c. End of Life Wishes (hospice care, funeral arrangements, etc.):

When I am near death, it is important to me that: [WRITE END-OF-LIFE WISHES HERE].

2. MEDICAL POWER OF ATTORNEY.

I, [PRINCIPAL NAME], as Principal, designate [AGENT NAME] as my agent to act in all matters relating to my health care (including my mental health care) and including, without limitation, the power to give or refuse consent to all medical and surgical treatments, hospitalizations and related health care. This power of attorney is effective at the point when I am no longer able to communicate my health care wishes. My agent’s decisions under this power of attorney, during any period when I am unable to make and/or communicate my health care decisions or when there is uncertainty as to whether I am dead or alive, are binding on my heirs, devisees, and personal representatives.

[INITIAL] – I specifically consent to giving my agent the power to admit me to an inpatient or partial psychiatric hospitalization program if ordered by my physician.
[INITIAL] – This Advance Directive, including Medical Power of Attorney, may not be revoked if I am incapacitated.

My agent’s address and phone number are as follows:

Agent Address: [AGENT ADDRESS]
Agent Phone Number: [AGENT PHONE NUMBER]

If my agent is unwilling or unable to serve, I hereby appoint [SUCCESSOR AGENT NAME] as my successor agent.

My successor agent’s address and phone number are as follows:

Successor Agent Address: [SUCCESSOR AGENT ADDRESS]
Successor Agent Phone Number: [SUCCESSOR AGENT PHONE NUMBER]

I intend for my agent to receive any and all of my health records and information as if I were the one requesting such information.

I have signed this document on [MM/DD/YYYY].

Principal’s Signature: ___________________________
Printed Name: [PRINCIPAL NAME]
Principal Address: [PRINCIPAL ADDRESS]
Principal Phone Number: [PRINCIPAL PHONE NUMBER]

You may either choose two witnesses or a notary to witness and acknowledge your signature.

WITNESS ACKNOWLEDGMENT

On the date set forth above, I (the witnesses) hereby state as follows:

The above-named person is personally known to me, and I believe them to be of sound mind and to have voluntarily executed this document. I am at least 18 years old, not related to them by blood, marriage, or adoption, and I am not an agent or successor agent named in this document. To my knowledge, I am not a beneficiary of their will or any codicil, and I have no claim against their estate. I am not directly involved in their health care.

Witness Signature: ___________________________
Printed Name: [WITNESS NAME]
Address: [WITNESS ADDRESS]
Phone: [WITNESS PHONE NUMBER]

Witness Signature: ___________________________
Printed Name: [WITNESS NAME]
Address: [WITNESS ADDRESS]
Phone: [WITNESS PHONE NUMBER]

NOTARY ACKNOWLEDGMENT

State of [STATE]
County of [COUNTY]

Signed and sworn to me this [MM/DD/YYYY].

I, the undersigned authority in and for said County in said State, hereby certify that the Principal [NOTARY ONLY: PRINCIPAL NAME], whose name is signed above in this living will and who is known to me, acknowledged before me on this day that, being informed of the contents of the said document, (s)he executed the same voluntarily on the day the same date.

Notary Public Signature: ___________________________
Printed Name: [NOTARY ONLY: NOTARY NAME]
My commission expires: [MM/DD/YYYY].

(Notary Seal)


How to Write

Download: PDF, Word (.docx), OpenDocument

This is a general guide to completing an advance directive document; the Advance Directive in the principal’s state of residence should always be used.

Colors:

  • Red – Required
  • Green – Optional

Section 1 – Living Will

Step 1 – Identifying the Principal

On the first (1st) page of the document, the principal will need to enter the following information:

  1. The current date
  2. Full name
  3. Street address (apt # included, if applicable)
  4. City
  5. County
  6. State
  7. Last four (4) digits of SSN

Step 2 – Life Support

Initial AND check any of the five (5) options presented. The 5th line can be used for specifying a type of quality of life not specified on the form. This whole section is optional; the principal is not required to select quality of life treatments.

Step 3 – Intravenous Food + Water

If the principal would like to kept alive by means of intravenous food and water (through a tube/needle), they should initial AND check the first option. If they would not like to be treated artificially, they should choose the second option. Only ONE (1) of the two (2) options listed should be selected.

Step 4 – Life-Sustaining Treatment

In the event of a medical emergency in which a medical professional states intervention is necessary to keep the principal alive, they will usually administer one (1) or all of the treatments listed in this section. The principal will need to check AND initial any of the five (5) means of treatment that they DO NOT want to receive should this situation arise.

Step 5 – End-of-Life Wishes

If the principal has any end-of-life requests, these can be included on the lines provided. An example could be “I would like to be brought home from the hospital to live out my final moments.”

If the principal runs out of space, they can attach a supplemental form, title it (e.g., “Appendix A”), and write the name of the additional document on one of the lines in section C.

Section 2 – Medical Power of Attorney

Step 6 – Agent Assignment

The agent is the individual that will represent the principal. They will inform doctors of the principal’s wishes and see that they are taken care of in the manner that was set forth in the “Living Will” section.

The principal will need to enter the following information into the appropriate fields:

  1. Principal’s full name
  2. Agent’s full name
  3. Principal’s initials (optional)
    • If the principal wishes to grant the agent the power to admit them to inpatient psychiatric care (if ordered by a physician), the first line should be initialed. If the principal also wishes to make the form NOT revocable upon their incapacitation (unable to communicate with those around them), the second line should be initialed.
  4. Agent’s address
  5. Agent’s phone number
  6. Successor (secondary) agent name (they will have power of attorney if the primary agent cannot perform their duties)
  7. Successor agent’s address
  8. Successor agent phone number

Step 7 – Principal’s Signature

The last step for the principal is to inscribe their signature on the document. This may need to be done in the presence of witnesses and/or a Notary Public, depending on the state the principal resides in. By signing the form, the principal is stating they understand and agree with all the information contained in the form. The following information will need to be provided in this section:

  1. Signing date
  2. Principal’s signature (by hand OR via eSign)
  3. Principal’s full printed name
  4. Principal’s address
  5. Principal’s phone number

Section 3 – Witnesses and/or Notarization

Step 8 – Witness Signature(s)

If required by the state, the principal may need to have one (1) or more witnesses sign the document after witnessing the principal sign their name. The witnesses CAN sign digitally via eSign as long as they are in the same physical location as the principal. The witnesses must provide their signature, printed name, address, and phone number in the appropriate fields as shown below.

Step 9 – Notarization

Some states allow the principal to notarize their signature instead of having witnesses sign the form. Alternatively, the principal may decide to have their Advance Directive notarized IN ADDITION to witnesses to add further proof as to the validity of the document. The principal can have the document notarized online by using eSign, or by visiting a post office, library, government office, or similar institution that has notary services available.


Frequently Asked Questions

Who can get an Advance Directive?

Any individual eighteen (18) years or older may create an advance directive. For individuals under eighteen (18) years of age, their parents or legal guardians are automatically nominated as their health care agents.

What are the signing requirements?

The majority of advance directives need to be signed by the principal, a notary, and two (2) witnesses. In most cases, a nurse, doctor, parent, and beneficiaries in a patient’s last will are not allowed to be witnesses to the execution of an advance directive.

Where can I register an Advance Directive?

An advance directive may be registered either at the local or state government level, or with a third (3rd) party. Registering is free in most states, sometimes a small fee will be charged. The following four (4) sites are reliable options for online registration:

What is incapacitation?

Incapacity defined by Section 102, Subsection 5 (Page 7) of the Uniform Power of Attorney Act:

“Incapacity” means inability of an individual to manage property or business affairs because the individual: (A) has an impairment in the ability to receive and evaluate information or make or communicate decisions even with the use of technological assistance; or (B) is: (i) missing;  (ii) detained, including incarcerated in a penal system; or (iii) outside the United States and unable to return.

Can a family member override an Advance Directive?

No, a family member cannot override the terms outlined in a living will unless specific instructions were given to the agent that permits them to do so.

Advance Directive vs Living Will vs Medical Power of Attorney

A living will is used for listing one’s preferences for medical treatment if they should become incapacitated (e.g., receive CPR, life support, etc.) A medical power of attorney nominates a person (the agent) to communicate one’s preferences to medical professionals.

The combination of both forms creates an advance directive, which contains instructions for treatment and nominates an agent to communicate said instructions.

Advance Directive vs Do Not Resuscitate (DNR)

An advance directive represents a patient’s medical decisions in case they cannot speak or make decisions for themselves. A do not resuscitate (DNR) informs all medical professionals NOT to perform any life-saving procedures on a patient.