Utah Advance Health Care Form PDF Details

In the landscape of health care decisions and end-of-life planning, the Utah Advance Health Care Directive emerges as a comprehensive legal instrument designed to ensure that individuals' health care preferences are respected and adhered to when they are unable to make decisions for themselves. This directive, honoring the stipulations under Utah Code Section 75-2a-117, is intricately divided into four main parts, each serving a unique and crucial role in the facilitation of health care decision-making. Part I grants individuals the authority to appoint an agent, a trusted person who will make health care decisions on their behalf, should they lose the capacity to do so. This section also provides the option to eschew the designation of an agent, catering to those who prefer not to appoint one. Part II is reserved for detailing specific health care wishes, essentially functioning as a living will. It is where individuals can make known their preferences regarding life-prolonging treatments, comfort care, or the refusal thereof. Part III guides on how one can revoke or amend the directive, ensuring that the document remains a true reflection of one's current health care desires. Lastly, Part IV legitimizes the document, delineating the process for making the directive a binding legal instrument. Through these sections, the Utah Advance Health Care Directive encapsulates a nuanced approach to planning for future health care, providing a structured format for individuals to articulate their health care preferences and select an advocate, if they so choose, thereby affording peace of mind and a sense of agency over future health care treatment.

QuestionAnswer
Form NameUtah Advance Health Care Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesut advanced directive, utah health directive form, utah health care directive, utah advanced care directive

Form Preview Example

UTAH ADVANCE HEALTH CARE DIRECTIVE

(Pursuant to Utah Code Section 75-2a-117)

Part I: Allows you to name another person to make health care decisions for you when you cannot make decisions or speak for yourself.

Part II: Allows you to record your wishes about health care in writing.

Part III: Tells you how to revoke the form.

Part IV: Makes your directive legal.

MY PERSONAL INFORMATION

Name:

Street Address:

City, State, Zip Code:

Telephone:

 

Cell Phone:

Birth date:

PART I: MY AGENT (HEALTH CARE POWER OF ATTORNEY)

A.No Agent

If you do not want to name an agent: initial the box below, then go to Part II; do not name an agent in B or C below. No one can force you to name an agent.

_______

I do not want to choose an agent.

(Initial)

B.My Agent

Agent's Name:

Street Address:

City, State, Zip Code:

Home phone:

 

Cell Phone:

 

Work phone:

C.Alternate Agent.

This person will serve as your agent if your agent, named above, is unable or unwilling to serve.

Alternate Agent's Name:

Street Address:

City, State, Zip Code:

Home phone:

 

Cell Phone:

 

Work phone:

D.Agent's Authority

If I cannot make decisions or speak for myself (in other words, after my physician or

APRN finds that I lack health care decision making capacity under Section 75-2a-104 of the Advance Health Care Directive Act), my agent has the power to make any health care decision I could have made such as, but not limited to:

•Consent to, refuse, or withdraw any health care. This may include care to prolong my life such as food and fluids by tube, use of antibiotics, CPR (cardiopulmonary resuscitation), and dialysis, and mental health care, such as convulsive therapy and psychoactive medications.

This authority is subject to any limits in paragraph F of Part I or in Part II of this directive.

•Hire and fire health care providers.

•Ask questions and get answers from health care providers.

•Consent to admission or transfer to a health care provider or health care facility, including a mental health facility, subject to any limits in paragraphs E and F of Part I.

•Get copies of my medical records.

•Ask for consultations or second opinions.

My agent cannot force health care against my will, even if a physician has found that I lack health care decision making capacity.

E.Other Authority

My agent has the powers below ONLY IF I initial the "yes" option that precedes the statement. I authorize my agent to:

YES _____ NO _____

Get copies of my medical records at any time, even when I

 

can speak for myself.

YES _____ NO _____

Admit me to a licensed health care facility, such as a

 

hospital, nursing home, assisted living, or other facility for

 

long-term placement other than convalescent or

 

recuperative care.

-2-

F.Limits/Expansion of Authority

I wish to limit or expand the powers of my health care agent as follows:

___________________________________________________________________

___________________________________________________________________

G.Nomination of Guardian

Even though appointing an agent should help you avoid a guardianship, a guardianship may still be necessary. Initial the "YES" option if you want the court to appoint your agent or, if your agent is unable or unwilling to serve, your alternate agent, to serve as your guardian, if a guardianship is ever necessary.

YES _____ NO _____

I, being of sound mind and not acting under duress, fraud,

 

or other undue influence, do hereby nominate my agent, or

 

if my agent is unable or unwilling to serve, I hereby

 

nominate my alternate agent, to serve as my guardian in the

 

event that, after the date of this instrument, I become

 

incapacitated.

H.Consent to Participate in Medical Research

 

YES _____ NO _____

I authorize my agent to consent to my participation in

 

 

medical research or clinical trials, even if I may not benefit

 

 

from the results.

I.

Organ Donation

 

 

YES _____ NO _____

If I have not otherwise agreed to organ donation, my agent

 

 

may consent to the donation of my organs for the purpose

 

 

of organ transplantation.

PART II: MY HEALTH CARE WISHES (LIVING WILL)

I want my health care providers to follow the instructions I give them when I am being treated even if my instructions conflict with these or other advance directives. My health care providers should always provide health care to keep me as comfortable and functional as possible.

Choose only one of the following options, numbered Option 1 through Option 4, by placing your initials before the numbered statement. Do not initial more than one option. If you do not wish to document end-of-life wishes, initial Option 4. You may choose to draw a line through the options that you are not choosing.

-3-

Option 1

_______

(Initial)

I choose to let my agent decide. I have chosen my agent carefully. I have talked with my agent about my health care wishes. I trust my agent to make the health care decisions for me that I would make under the circumstances.

Additional Comments: ________________________________________________________

Option 2

_______

(Initial)

I choose to prolong life. Regardless of my condition or prognosis, I want my health care team to try to prolong my life as long as possible within the limits of generally accepted health care standards.

Other: _____________________________________________________________________

Option 3

_______

(Initial)

I choose not to receive care for the purpose of prolonging life, including food and fluids by tube, antibiotics, CPR, or dialysis being used to prolong my life. I always want comfort care and routine medical care that will keep me as comfortable and functional as possible, even if that care may prolong my life.

If you choose this option, you must also choose either (a) or (b), below.

_______

(a) I put no limit on the ability of my health care provider or

(Initial)

agent to withhold or withdraw life-sustaining care.

If you selected (a), above, do not choose any options under (b).

_______

(b) My health care provider should withhold or withdraw

(Initial)

life-sustaining care if at least one of the following initialed

 

conditions is met:

_____

I have a progressive illness that will cause death.

(Initial)

 

_____

I am close to death and am unlikely to recover.

(Initial)

 

_____

I cannot communicate and it is unlikely that my

(Initial)

condition will improve.

_____

I do not recognize my friends or family and it is

(Initial) unlikely that my condition will improve.

_____

I am in a persistent vegetative state.

(Initial)

 

Other: _____________________________________________________________________

-4-

Option 4

_______ I do not wish to express preferences about health care wishes in this

(Initial) directive.

If you do not want emergency medical service providers to provide CPR or other life sustaining measures, you must work with a physician or APRN to complete an order that reflects your wishes on a form approved by the Utah Department of Health.

PART III: REVOKING OR CHANGING A DIRECTIVE

I may revoke or change this directive by:

1.Writing "void" across the form, or burning, tearing, or otherwise destroying or defacing this document or directing another person to do the same on my behalf;

2.Signing a written revocation of the directive, or directing another person to sign a revocation on my behalf;

3.Stating that I wish to revoke the directive in the presence of a witness who is 18 years of age or older; will not be appointed as my agent in a substitute directive; will not become a default surrogate if the directive is revoked; and signs and dates a written document confirming my statement; or

4.Signing a new directive. (If you sign more than one Advance Health Care Directive, the most recent one applies.)

PART IV: MAKING MY DIRECTIVE LEGAL

I sign this directive voluntarily. I understand the choices I have made and declare that I am emotionally and mentally competent to make this directive. My signature on this form revokes any living will or power of attorney form, naming a health care agent, that I have completed in the past.

___________________

________________________________________________

Date

Print name: ________________________

___________________________________________________________________________

City, County, and State of Residence

I have witnessed the signing of this directive, I am 18 years of age or older, and I am not:

1.Related to the declarant by blood or marriage;

2.Entitled to any portion of the declarant's estate according to the laws of intestate succession of any state or jurisdiction or under any will or codicil of the declarant;

-5-

3.A beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transfer or death deed that is held, owned, made, or established by, or on behalf of, the declarant;

4.Entitled to benefit financially upon the death of the declarant;

5.Entitled to a right to, or interest in, real or personal property upon the death of the declarant;

6.Directly financially responsible for the declarant's medical care;

7.A health care provider who is providing care to the declarant or an administrator at a health care facility in which the declarant is receiving care; or

8.The appointed agent or alternate agent.

_______________________________

_______________________________________

Signature of Witness

Printed Name of Witness

 

_________________________________

______________

_________

_________

Street Address

City

State

Zip Code

If the witness is signing to confirm an oral directive, describe below the circumstances under which the directive was made.

-6-

How to Edit Utah Advance Health Care Form Online for Free

Handling PDF files online is actually super easy using our PDF tool. You can fill in utah advance health care directive here effortlessly. To make our tool better and more convenient to utilize, we consistently work on new features, with our users' suggestions in mind. To get the ball rolling, consider these easy steps:

Step 1: Just click the "Get Form Button" at the top of this page to get into our form editor. This way, you will find all that is required to fill out your file.

Step 2: When you launch the editor, there'll be the form prepared to be filled out. In addition to filling out different fields, you could also perform many other things with the file, such as adding any textual content, modifying the original text, inserting graphics, putting your signature on the document, and more.

It will be an easy task to complete the pdf following this helpful guide! This is what you must do:

1. The utah advance health care directive will require certain information to be entered. Be sure the next blank fields are filled out:

utah directive writing process detailed (part 1)

2. After the previous segment is complete, it is time to insert the needed details in My Agent, B Agents Name, Street Address, City State Zip Code, and Home phone Cell Phone Work phone so you're able to move forward to the next part.

Writing segment 2 in utah directive

Those who use this document frequently make mistakes while completing City State Zip Code in this section. You should re-examine whatever you type in here.

3. This next step is related to C This person will serve as your, Alternate Agents Name, Street Address, City State Zip Code, Home phone Cell Phone Work phone, Agents Authority If I cannot make, cid, Consent to refuse or withdraw any, cid cid cid, and Hire and fire health care - fill out these blanks.

Stage # 3 of completing utah directive

4. The following paragraph requires your involvement in the subsequent places: E My agent has the powers below, YES NO, Get copies of my medical records, YES NO, and Admit me to a licensed health care. Make certain you type in all of the needed info to go further.

Filling out part 4 of utah directive

5. To wrap up your document, this last section has some extra blank fields. Filling in LimitsExpansion of Authority, F I wish to limit or expand the, Nomination of Guardian, G Even though appointing an agent, YES NO, I being of sound mind and not, Consent to Participate in Medical, and I authorize my agent to consent to will conclude everything and you will be done before you know it!

LimitsExpansion of Authority, I being of sound mind and not, and Nomination of Guardian inside utah directive

Step 3: Prior to moving forward, ensure that all form fields have been filled in right. Once you think it is all fine, click “Done." Right after registering afree trial account with us, it will be possible to download utah advance health care directive or email it at once. The PDF document will also be readily available in your personal account page with all of your edits. Here at FormsPal.com, we endeavor to guarantee that all your information is kept protected.

Utah Advance Health Care Form isn’t the one you’re looking for?

Related Documents