Can an ACP be signed electronically?

Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states provided intent, consent, attribution, and reliable record retention are satisfied.

Are witnesses always required?

Witness requirements depend on state law. Some states require one or two witnesses for advance directives; others accept notarization instead. Follow the patient’s domiciliary state rules.

Does an electronic ACP require a BAA?

If the ACP contains protected health information and a vendor processes PHI, a Business Associate Agreement (BAA) is required under HIPAA before sharing records.

What if the patient changes their mind?

An ACP can be revoked or amended by the patient while competent. Document revocations in writing, notify agents and clinicians, and replace prior versions in the record.

Can RON be used for notarization?

Remote Online Notarization is permitted in most states with specific identity-proofing and recording requirements; verify the state’s RON rules before relying on remote notarization.

How should signed ACPs be distributed?

Provide copies to the designated agent, primary care clinician, any specialists, and upload a copy to the EHR. Maintain a retention copy per HIPAA and state retention rules.

Electronic Signature
Templates
Healthcare
Healthcare ACP Agreement

Healthcare ACP Agreement

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE ACP AGREEMENT

Patient Information

Patient Name

Date of Birth: Gender: Medical Record No.:

Address Primary Phone Emergency Contact

Insurance Information

Primary Insurer Policy / ID Number Group Number Subscriber Name

Medical History (Summary)

Current Medications Allergies Prior Surgeries / Significant Procedures Chronic Conditions / Diagnoses

Appointment of Healthcare Agent

I designate the following person as my healthcare agent with authority to make healthcare decisions on my behalf if I am unable to do so:
Agent Name: Relationship:

Agent Phone: Agent Address:

Alternate Agent Name: Alternate Agent Phone:

Preferences for Medical Treatment

Indicate your preferences by selecting options below and providing additional instructions where applicable. Where options conflict, the most specific instruction governs.

Full Treatment (use all medically indicated life-sustaining treatments)
Do Not Resuscitate / Do Not Intubate (DNR / DNI) — withhold CPR and endotracheal intubation
Comfort Measures Only (focus on comfort, relieve pain; no life-prolonging interventions)
Limited Interventions (specify limits below)

Limits (if Limited Interventions selected):
Withhold CPR
Withhold mechanical ventilation
Withhold IV antibiotics for life-prolonging treatment
Withhold long-term artificial nutrition/hydration
Withhold dialysis

Other Specific Instructions (e.g., pain control, hospitalization, transfusions)

Goals, Values and Personal Statements

Describe what matters most to you and what outcomes you consider acceptable or unacceptable. These statements will guide decisions when specific treatment choices are not described above.

What matters most to me Outcomes I would find unacceptable

Authority, Limitations and Scope

By signing this Agreement I authorize my healthcare agent to make health care decisions on my behalf, including consenting to or refusing medical treatment, accessing medical records, and determining disposition of my body, consistent with the expressed preferences in this Agreement. The agent's authority is subject to any specific limitations written herein.

Agent Limitations or Conditions

HIPAA Authorization and Release of Information

I authorize healthcare providers and facilities to disclose my protected health information to my appointed healthcare agent to the extent necessary for the agent to carry out health care decision-making authorized by this Agreement. This authorization includes medical records, treatment plans, and related information.

I acknowledge and consent to the HIPAA authorization above.

Effective Date, Duration and Revocation

This Agreement becomes effective immediately upon execution and remains in effect until revoked. I may revoke this Agreement at any time by communicating my intent to revoke to my healthcare providers or my appointed agent, whether orally or in writing. A healthcare provider may rely on a good faith belief that this Agreement is in effect until notified otherwise.

Expiration Date (optional):

Miscellaneous Provisions

Effect of Copies: A photocopy, electronic copy, or facsimile of this Agreement shall have the same effect as the original. Interpretation: If any provision of this Agreement is held invalid, the remaining provisions shall continue in full force and effect. Governing Law: This Agreement shall be interpreted under applicable law of the jurisdiction where the patient is primarily treated.

Acknowledgment and Certification

I certify that I understand the nature and effect of this Healthcare ACP Agreement, that the choices recorded reflect my wishes, and that I am signing this Agreement voluntarily and with capacity to make healthcare decisions at the time of signing. If signing as a guardian or legal representative, I certify that I am legally authorized to make decisions on behalf of the patient and will provide documentation of that authorization upon request.

Patient Name:

Signature:

Date:

What the Healthcare ACP Agreement is and when it applies

The Healthcare ACP Agreement (Advance Care Planning Agreement) records a patient's preferences for future medical care, designates decision-makers, and documents instructions for treatments and end-of-life care. It typically names a healthcare agent or proxy, specifies life-sustaining treatment preferences, and may include organ donation or DNR instructions. The document is used when a patient cannot make or communicate decisions and is intended to guide clinicians, family members, and legal representatives. Proper completion, witness or notary steps, and secure storage help ensure the agreement is followed by care teams and honors the patient’s values.

Why a clear Healthcare ACP Agreement matters for care and legal clarity

A completed Healthcare ACP Agreement provides legally admissible evidence of patient intent, clarifies decision-making authority, and reduces conflict in medical emergencies. It guides clinicians and supports ethical, patient-centered care while helping institutions meet documentation requirements under applicable health regulations and facility policies.

Who typically completes and relies on a Healthcare ACP Agreement

Identifying each participant and their role when completing and storing the document helps ensure it will be found and followed when needed.

Patients and proxies who want clear instructions for future incapacity and end-of-life decisions.
Primary care and hospital clinicians who must follow patient directives during treatment.
Healthcare facilities and legal counsel responsible for recordkeeping and compliance.

Step-by-step: completing a Healthcare ACP Agreement

Follow these sequential steps to prepare a legally useful and clinically actionable agreement.

01

Prepare: Gather patient ID and contact details for agents and alternates.
02

Document: Complete name, DOB, agent, scope, and treatment preferences.
03

Authenticate: Obtain required witness signatures or notary acknowledgement.
04

Distribute: Share copies with agent, primary clinician, and health record.

How electronic completion and routing typically works

A standard e-workflow reduces delays and documents consent through an audit trail.

Upload Document: Sender uploads the ACP form to the signing platform.
Place Fields: Add signature, date, and witness/notary fields as required.
Send to Signers: Send secure signing links or email invites to patient and signers.
Capture Audit Trail: Platform logs timestamp, IP, and actions for legal evidence.

Configuring an online Healthcare ACP signing workflow

Set up the digital workflow to match legal and clinical authentication requirements before sending for signatures.

Field	Configuration
Signature Type	Electronic signature with audit trail
Witness Fields	Conditional witness fields when state law requires them
Notary Options	Allow Remote Online Notarization (RON) when permitted
Recipient Routing	Set signing order: patient → witness → notary → clinician

Technology and integration considerations for eSigning Healthcare ACPs

Verify platform support for workflows, audit trails, EHR export, and any required BAAs before processing protected health information.

Integrations: Connects to EHRs and document stores
File Formats: Supports PDF and DOCX formats
Authentication: Offers multi-factor signer verification

Security, encryption, and compliance elements to expect

Encryption in transit: TLS 1.2/1.3

Encryption at rest: AES-256

HIPAA compliance: BAA required for PHI

Audit trail: Timestamps, IP, action log

Certifications: SOC 2 Type II, ISO 27001

Regulatory support: 21 CFR Part 11 available

Legal risks and penalties for improper or incomplete ACP agreements

Invalid authorization: Document may be unenforceable without required witnesses

HIPAA violations: Potential fines and corrective actions

Medicaid/Medicare issues: Coverage disputes if instructions unclear

State law noncompliance: May void proxy powers or directives

Medical liability: Clinicians risk exposure for noncompliance

Recordkeeping penalties: Failure to retain could breach regulations

Common mistakes to avoid when preparing a Healthcare ACP Agreement

Leaving signature or witness blocks blank — missing authentication is a frequent cause of rejection.
Using ambiguous language for treatment choices — vague terms create interpretive disputes in emergencies.
Failing to identify successor agents — do not rely on a single named individual without alternates.
Not distributing copies to clinicians and EHRs — undistributed directives may not be available at point of care.

Timing considerations and processing expectations

Understand key timing elements: when the agreement takes effect, when it should be recorded in records, and when renewals are recommended.

Effective date selection:

Enter MM/DD/YYYY; determines when directives become operative

Record entry:

Upload signed copy to EHR immediately upon completion

Periodic review:

Recommend annual review or after major health changes

Notary/witness scheduling:

Arrange witnesses or RON before clinical transfer or surgery

Agent notification:

Notify designated agents as soon as document is final

eSignature vendor comparison for Healthcare ACP Agreement workflows

Compare basic pricing and capabilities across providers; signNow is listed first to align column ordering policies.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
Envelope Cap	No envelope cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions about executing a Healthcare ACP Agreement

Answers to common practical and legal questions that arise when completing, signing, or revising an ACP.

Need help? Contact support

Can an ACP be signed electronically?
Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states provided intent, consent, attribution, and reliable record retention are satisfied.
Are witnesses always required?
Witness requirements depend on state law. Some states require one or two witnesses for advance directives; others accept notarization instead. Follow the patient’s domiciliary state rules.
Does an electronic ACP require a BAA?
If the ACP contains protected health information and a vendor processes PHI, a Business Associate Agreement (BAA) is required under HIPAA before sharing records.
What if the patient changes their mind?
An ACP can be revoked or amended by the patient while competent. Document revocations in writing, notify agents and clinicians, and replace prior versions in the record.
Can RON be used for notarization?
Remote Online Notarization is permitted in most states with specific identity-proofing and recording requirements; verify the state’s RON rules before relying on remote notarization.
How should signed ACPs be distributed?
Provide copies to the designated agent, primary care clinician, any specialists, and upload a copy to the EHR. Maintain a retention copy per HIPAA and state retention rules.

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