Healthcare Advance Directive Notification

Healthcare Advance Directive Notification

This form notifies the health care facility and treating clinicians that the patient named below has executed one or more advance directive documents that express decisions about future health care and/or appoint an agent to make health care decisions on the patient's behalf. Completion of this notification does not itself create an advance directive; it documents the existence, type, location, and agent information for directives already executed by the patient.

Patient Information

Patient Name:

Date of Birth:

Insurance Information

Medical History (for chart reference)

Advance Directive Details

Types of advance directive on file (check all that apply):

Living Will / Declaration of Wishes

Health Care Proxy / Durable Power of Attorney for Health Care

Do Not Resuscitate (DNR) / No Code

POLST / Medical Orders for Life-Sustaining Treatment

Organ / Tissue Donation Authorization

Other:

Date Executed:

Jurisdiction Where Executed:

Original Document Location (check one and provide details if applicable):

In patient medical record/chart

With appointed agent at:

With attorney (firm):

Other (describe):

Agent / Proxy Information

Acknowledgment and Authority

By signing below, the patient (or authorized representative) confirms that one or more advance directive documents have been executed and that the information provided above accurately reflects the existence, type, and location of such document(s). The patient authorizes the facility to:

- Place a copy or summary of the advance directive(s) in the medical record; and

- Communicate with the designated agent and, to the extent necessary for treatment and care coordination, provide copies of relevant medical information to the agent identified above.

The patient retains the right to revoke or amend any advance directive at any time and may provide a revocation in writing or by verbally notifying treating clinicians. The facility will make reasonable efforts to document revocations and to notify the agent and treating team.

Witness / Notary (if applicable)

Witnesses or notary information relevant to the attached directive documents may be recorded here. If the patient executed the directive in the presence of witnesses or a notary, complete applicable fields below.

Administrative Use — Staff Acknowledgment

Staff completing review of advance directive documentation should record details below. This section documents verification only and is not a substitute for the original advance directive.

Expiration / Revocation

This notification remains in effect until the patient revokes it or submits an updated notification. Please indicate if the advance directive has a specified expiration:

Indefinite until revoked by the patient

Expires on:

Patient Certification

I certify under penalty of perjury under the laws of the applicable jurisdiction that the information provided on this form is true and correct to the best of my knowledge and that I have executed the advance directive(s) identified above or am the authorized representative of the patient with authority to provide this notification.

I understand that I may revoke or amend an advance directive at any time by providing written notice to the treating facility or by verbally notifying treating clinicians, and that the facility will make a reasonable effort to document such revocation.

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