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Advance Health Care Directive

The following form is the advanced health care directive form. It consists of 5 key elements.

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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 thin\
gs.  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. 	
INSTRUCTIONS 
Part 1: Power of Attorney 	
Part 1 lets you: 
PS-X-MHS-442  (Rev. 3-04)	  MPS/pmd

Part 3: Donation of Organs 
You can write down your wishes about donating 
your bodily organs and tissues following your death. 
Part 4: Primary Physician 
You can select a physician to have primary or main 
responsibility for your health care. 
Part 5: Signature and Witnesses 
After completing the form, sign and date it in the 
section provided. 
The form must be signed  by two qualified 
witnesses  (see the statements of the witnesses  included in the form) 
or acknowledged before a 
notary public.  A notary is not required if the 
form is signed by two witnesses.  The wittnesses 
must sign the form on the same date it is signed 
by the  person making the Advance Directive. 
See part 6 of the form if you are a patient in a 
skilled nursing facility. 	
Part 6: Special Witness Requirement 
A Patient Advocate or Ombudsman must witness 
the form  if you are a patient in a skilled nursing 
facility  (a health care facility that provides skilled 
nursing care and supportive care to patients). 
See Part 6 of the form. 	
You have the right to change or revoke your Advance Health Care Directive  at any time 	
 If you have questions about completing the Advance Directive in the hospital, please ask to speak to a Chaplain or Social Worker. 	
We ask that you 
complete this form in English 
so your caregivers can understand your directions.

________________________________________________________________________\
________ 
________________________________________________________________________\
________ 
________________________________________________________________________\
________ 	
Advance Health Care Directive 
Name________________________________________ 
Date _________________________________________ 
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.  This form also lets you write down your wishes
regarding donation of organs and the designation of your primary physici\
an.  If you use this form, you may
complete or change all or any part of it.  You are free to use a different form	
. 	
You have the right to change or revoke this advance health care directive\
 at any time. 
Part 1 — Power of Attorney for Health Care

________________________________________________________________________\
_________________ 
________________________________________________________________________\
_________________ 
________________________________________________________________________\
_________________ 
________________________________________________________________________\
_________________ 
PS-X-MHS-842  (Rev. 2-04)  Page 2 of 4  MPS/PMD

________________________________________________________________________\
___________________________________ 
________________________________________________________________________\
___________________________________ 
________________________________________________________________________\
___________________________________ 
________________________________________________________________________\
___________________________________ 
________________________________________________________________________\
___________________________________ 
________________________________________________________________________\
______   
PS-X-MHS-842  (Rev. 2-04)  Page 3 of 4  MHS/PMD

FIRST WITNESS 
Print Name: 
________________________________________________________________________\
______ 
Address:  ________________________________________________________________________\
______ 
Signature of Witness:  ________________________________________  Date: ________________________ 
SECOND WITNESS 
Print Name:  ________________________________________________________________________\
______ 
Address:  ________________________________________________________________________\
______ 
Signature of Witness:  ________________________________________  Date: ________________________ 	
PS-X-MHS-842  (Rev. 2-04)  Page 4 of 4  MPS/PMD
Relevant article from our knowledge database

You may also use an advance directive to state what sorts of treatments you do or don't want, especially the treatments frequently used in a health emergency or close to the conclusion of somebody's life. You may choose to make more than 1 advance directive. You're able to download a California Advance Directive in English in addition to several different languages. The most essential thing on an advance directive is what you conductn't want your health care provider to conduct otherwise a physician will usually conduct everything in his power he feels is needed. The Advance medical Care Directive is important in the event you are incapacitated because it enables you to appoint a medical care agent who has the authority to earn decisions based on your present wishes.
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In case the individual has not chosen a medical Care Agent, the doctor is still required to stick to the persons wishes, as expressed in the Individual healthcare Instructions. He may specify a shorter time if they choose. He may choose to complete either one or both of these parts. The individual making the Advance Directive should maintain a copy in a secure, but accessible spot. These medications may or may not be the same medications he takes routinely. It's not essential for the man or woman to mention an agent or write Individual Health Care Instructions so as to finish an Advance Directive, but the individual must finish the signature section as a way to earn a valid Advance Directive.

The services offered will be a total estate program, including a living trust. Furthermore, before implementing a medical care choice made for the individual, the doctor must promptly inform the individual about the choice and the identity of the individual making the choice. You may want to speak to your doctor or attorney to be sure you have finished the living will in a manner your wishes will be understood.

Next: Arkansas Durable Power of Attorney for Health Care (Arkansas Statute Sec 20-13-104) Previous: Advance Directive for Medical and Surgical Treatment (Living Will)
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