Is an electronic signature valid?

Yes. Under the ESIGN Act (15 U.S.C. ch. 96) and UETA, electronic signatures are legally valid when intent, consent, attribution, and record retention criteria are met. Confirm state-specific exceptions such as wills or certain court filings before e-signing.

When is notarization required for this form?

Notarization and witness requirements vary by state and by the type of advance directive. Some jurisdictions accept unsigned electronic copies; others require a notary or two witnesses. Verify local rules with the state health department or probate office before final execution.

Does HIPAA affect e-signature handling?

Yes. Healthcare entities must protect PHI when using e-signatures and may need a Business Associate Agreement with the e-sign vendor. Maintain access controls, audit logs, and retention consistent with HIPAA (45 CFR §164.530(j)).

Can I update a signed form?

You can revise preferences by completing a new signed form dated and signed, or by using an addendum. Retain prior versions and document the reason for change; distribute the updated copy to clinicians and surrogates to avoid conflicts.

Who should sign the form?

The patient signs when competent; if incapacitated, the designated surrogate or legally authorized representative signs per state law. Clinician attestation confirming discussion is recommended. In some states a witness or notary signature is also necessary for enforceability.

How do I store and access copies?

Store signed originals in the medical record and maintain encrypted electronic copies with audit trails. Limit access to authorized personnel, retain copies per HIPAA and federal guidance, and ensure portability for transfers between facilities or hospice providers.

Electronic Signature
Templates
Healthcare
Healthcare Comfort Care Form

Healthcare Comfort Care Form

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

Healthcare Comfort Care Form

This Comfort Care Form records the expressed preferences of the patient regarding goals of care and the provision of comfort-focused medical treatment. Completion of this form indicates a desire to prioritize relief of distressing symptoms and quality of life rather than interventions intended to prolong life when those interventions would not provide comfort or meaningful recovery.

Patient Information

Patient Full Legal Name

Date of Birth: Gender:

Address

Primary Phone: Alternate Phone:

Emergency Contact

Name

Relationship: Phone:

Insurance / Coverage

Primary Insurance Provider

Policy Number: Group Number:

Subscriber Name

Clinical Background

Current Medications Allergies and Adverse Reactions Significant Past Surgeries / Procedures Chronic Conditions / Diagnoses

Advance Directive

I have an advance directive or durable power of attorney for healthcare: Yes No

If yes, name of appointed agent or location of directive

Comfort Care Preferences

I request that to the extent permitted by law my clinical team provide treatments focused on comfort, relief of distressing symptoms, dignity and quality of life, and withhold or withdraw interventions primarily intended to prolong life when such interventions would not provide comfort or benefit.

For specific interventions, I request the following be withheld if they are not needed for comfort or if they would not offer meaningful recovery:

Withhold cardiopulmonary resuscitation (CPR) / Do Not Attempt Resuscitation

Withhold endotracheal intubation and mechanical ventilation

Withhold artificial nutrition and hydration (feeding tubes) when unlikely to improve comfort or outcome

Withhold dialysis for life-prolongation when it does not provide comfort

Avoid transfer to higher-level acute care for interventions intended to prolong life when comfort can be delivered in current setting

I request that the following comfort measures be provided unless contraindicated:

Administration of analgesics and sedatives to relieve pain or distress, even if they may indirectly hasten death

Oxygen, bronchodilators, and suctioning when used for comfort

Use of antibiotics when primarily indicated to relieve distressing symptoms

Palliative sedation for refractory symptoms to achieve comfort

Additional specific instructions regarding goals of care or interventions

Spiritual, Cultural, and Personal Wishes

Spiritual or cultural preferences that should be honored

Acknowledgments and Legal Statements

By signing below I confirm that (1) I am competent to make healthcare decisions for myself and this reflects my current wishes concerning comfort-focused care; (2) I have had the opportunity to discuss the goals of comfort care, expected benefits, and foreseeable risks with a member of my clinical care team; (3) I understand that withholding or withdrawing certain life-sustaining treatments may result in death sooner than if such treatments were used; and (4) I may revoke or modify this Comfort Care Form at any time while I remain decisionally capable.

I authorize clinical personnel to place this Comfort Care Form in my medical record and to communicate these preferences to other treating clinicians and facilities involved in my care.

This form is intended to guide medical decision-making and does not replace any legally executed advance directive or durable power of attorney for healthcare. If there is a conflict between this form and a valid advance directive or legally-appointed decision maker, the advance directive or decision maker shall control to the extent permitted by law.

Authorization Expiration Date (optional)

I understand that this Comfort Care Form may be reviewed by my treating clinicians and may inform orders in outpatient, emergency, inpatient, hospice, or long-term care settings.

I consent to the use and disclosure of information in this form to the clinical team responsible for my care to the extent necessary to honor the preferences contained herein.

Patient Printed Name:

Signature:

Date:

If signed by a legal guardian or representative, state relationship:

By signing above, the signer attests under penalty of perjury that they are the patient or the legally authorized representative acting on behalf of the patient, and that the information and preferences expressed in this Comfort Care Form are truthful and accurately reflect the patient's wishes to the best of the signer's knowledge.

What the Healthcare Comfort Care Form Is

The Healthcare Comfort Care Form documents a patient's preferences for comfort-focused treatment when curative care is no longer effective. It records choices about pain management, symptom relief, use of artificial nutrition and hydration, and preferred setting of care. Providers, surrogate decision-makers, and legal representatives use the form to guide bedside and hospice care. Completed forms can accompany advance directives and medical orders to ensure care aligns with patient goals. This page explains what the form captures, who completes it, and how electronic signatures and secure storage support lawful, accessible records.

Why a Clear Comfort Care Form Matters

A Healthcare Comfort Care Form clarifies patient wishes, reduces uncertainty during serious illness, and documents legal instructions for clinicians and surrogates. Clear documentation helps align care with goals, speeds clinical decision-making, and reduces conflicts among family, care teams, and facilities.

Who Typically Completes and Uses This Form

Who completes this form depends on the setting: patients, clinicians, or authorized surrogates may prepare or sign the document.

Patients — adults with decisional capacity who want to document comfort-focused treatment preferences.
Surrogates or legally authorized representatives — act when the patient lacks capacity under state law.
Clinicians and hospice staff — use the form to guide symptom management and end-of-life care plans.

Institutions commonly place the signed form in the medical record and may require additional consent or authorization consistent with HIPAA.

Representative Signers and Roles

Patient

A competent adult patient fills and signs the Healthcare Comfort Care Form to express preferences for symptom relief, analgesia, and limitations on life-sustaining interventions. Accurate entries and dated signatures ensure clinicians can rely on the document during acute deterioration and support legal portability between care settings.

Clinician

Physicians, nurse practitioners, and hospice clinicians complete or review the form to document medically appropriate comfort measures and coordinate orders. Clinician verification of diagnosis, prognosis, and treatment options strengthens the form's clinical utility and reduces ambiguity for downstream caregivers.

Step-by-Step: Completing the Form

Follow these sequential steps to complete, validate, and securely store the Healthcare Comfort Care Form electronically.

01

Confirm Capacity: Assess and document patient decision-making capacity before completing.
02

Discuss Options: Review comfort measures, analgesia, and life-sustaining preferences together.
03

Complete Fields: Enter precise choices, dates, and contact information accurately.
04

Sign & Distribute: Obtain signatures, date, and share copies with care team.

Configure an Online Workflow for the Form

Configure an online workflow to collect, authenticate, and archive Healthcare Comfort Care Forms securely and automate distribution.

Field or Setting Name in Workflow	Configuration
Signature Type	Electronic signature with audit trail
Authentication Method	Email link, SMS code, or ID verification
Storage Location	EHR integration or secure cloud archive
Notification Routing	Auto-send copies to listed clinicians and surrogates

How the Form Moves Through Care Workflows

Typical routing for the form shows how it moves between patient, clinician, and record systems.

Upload: Add the completed PDF or digital form to the EHR or cloud storage.
Authenticate: Verify signer identity using ID, SMS code, or KBA where needed.
Sign: Apply signatures—electronic or handwritten scanned—plus dates and initials.
Archive: Store signed versions with audit trail in medical record.

Platform and Integration Considerations

Platform and integration requirements determine how forms are shared, authenticated, and stored across clinical systems.

Integrations: EHR, Google Workspace, Box, NetSuite supported
Formats: PDF, DOCX, and editable templates
Authentication: SMS, email, KBA, and SSO options

Key Components Included in a Professional Form

Core sections define medical context, patient priorities, surrogate authority, specific comfort interventions, legal attestations, and distribution instructions for the Healthcare Comfort Care Form.

Medical Context

State diagnosis, prognosis, current clinical status, and clinician summary so that comfort decisions are grounded in the patient's medical condition and clearly linked to treatment options discussed.

Patient Priorities

Specify goals such as 'maximize comfort', acceptable side effects, preferences regarding sedation levels, location of care, and who may make decisions if the patient cannot.

Surrogate Authority

Name the primary surrogate, include contact information, legal relationship, and any limits on decision-making authority; indicate whether HIPAA release is granted for medical discussions and document alternates.

Comfort Interventions

List permitted and prohibited measures, such as use of opioids, oxygen, noninvasive ventilation, and whether artificial nutrition or hydration is acceptable under specified circumstances with duration preferences.

Legal Attestation

Include dated signature lines for patient and witnesses or notary where required, and a clinician attestation verifying discussion of benefits, risks, and alternatives and document location of care discussions.

Distribution

Specify who receives copies—primary care, specialists, hospice, and family—and whether a copy is uploaded to the EHR, cloud storage, or carried by the patient and include version date.

Security and Compliance Basics for Electronic Copies

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

Certifications: SOC 2 Type II; ISO 27001; PCI DSS

HIPAA: BAA available; protects PHI

ESIGN/UETA: Meets federal and state e-sign laws

Audit Trail: Detailed timestamps, IPs, action logs

Access Controls: Role-based permissions and MFA options

Best Practices to Improve Accuracy and Usefulness

Follow these best practices to ensure the form is clear, enforceable, and available when needed.

Use clear and specific language

Avoid vague phrases; describe concrete interventions and limits, define acceptable side effects, and state triggers for implementation so clinicians and surrogates can translate preferences into care decisions without subjective interpretation.

Confirm local legal and institutional requirements

Check state law, facility policy, and whether witness or notary signatures are required; obtain any separate HIPAA authorizations needed to share details with third-party caregivers or family members and retain copies in the EHR.

Keep the form current and reviewed annually

Review the form after major health changes, hospitalizations, or legal status changes; document revisions with new dates and signatures and distribute updated copies to all previously notified parties including primary care and hospice.

Store signed copies securely in the EHR

Maintain tamper-evident electronic copies with audit trails, restrict access by role, and ensure retention meets HIPAA and federal recordkeeping standards so the document remains admissible and available during care transitions.

Common Preparation Pitfalls to Avoid

Leaving key sections blank—such as preferences for nutrition or resuscitation—creates ambiguity and forces clinicians to default to maximal interventions.
Using vague language like 'do not prolong life' without defining acceptable comfort measures can lead to inconsistent interpretation across care teams.
Failing to sign or date the form, or signing in the wrong field, may render it legally unenforceable in emergencies.
Not providing a copy to primary care clinicians, hospice, or the medical record reduces effectiveness when care transitions occur.

Consequences of an Incorrect or Incomplete Form

Clinical Risk: Care delivered contrary to documented wishes

Legal Liability: Potential malpractice or wrongful-death claims

Regulatory Exposure: HIPAA violations if PHI mishandled

Invalid Authorization: Unsigned or mismatched names can invalidate

Operational Delays: Confusion leads to slower decision-making

Civil Penalties: State fines or sanctions possible

When to Complete and Review the Form

Timing matters: complete the form during stable visits and review when health status changes or prior to discharge.

At first primary care visit:

Discuss preferences and record initial choices.

Before planned hospital discharge or transfer:

Confirm form, clinician notes, and distribution.

After major new diagnosis or prognosis:

Update preferences and obtain new signatures.

Annual review during routine primary care visit:

Review, revise, and redistribute as needed.

Upon transfer to hospice or facility:

Ensure receiving team has the latest signed copy.

Key Milestones from Completion to Review

Key milestones track completion, verification, distribution, and periodic review of the Healthcare Comfort Care Form.

01

Form Completion

Patient or surrogate completes choices and signs.

02

Clinical Review

Clinician documents prognosis and discusses options.

03

Witnessing/Notarization

Obtain witness signatures or notary if required.

04

Record Retention

Upload to EHR and distribute copies.

eSignature Pricing and Feature Comparison

Compare typical starting prices and core features of common e-signature vendors relevant to Healthcare Comfort Care Form workflows.

	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, no card required	Trial varies by vendor	Trial varies by vendor	Trial varies by vendor	Trial varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions

Answers to common questions about completing, signing, and storing the Healthcare Comfort Care Form electronically and in paper form.

Need help? Contact support

Is an electronic signature valid?
Yes. Under the ESIGN Act (15 U.S.C. ch. 96) and UETA, electronic signatures are legally valid when intent, consent, attribution, and record retention criteria are met. Confirm state-specific exceptions such as wills or certain court filings before e-signing.
When is notarization required for this form?
Notarization and witness requirements vary by state and by the type of advance directive. Some jurisdictions accept unsigned electronic copies; others require a notary or two witnesses. Verify local rules with the state health department or probate office before final execution.
Does HIPAA affect e-signature handling?
Yes. Healthcare entities must protect PHI when using e-signatures and may need a Business Associate Agreement with the e-sign vendor. Maintain access controls, audit logs, and retention consistent with HIPAA (45 CFR §164.530(j)).
Can I update a signed form?
You can revise preferences by completing a new signed form dated and signed, or by using an addendum. Retain prior versions and document the reason for change; distribute the updated copy to clinicians and surrogates to avoid conflicts.
Who should sign the form?
The patient signs when competent; if incapacitated, the designated surrogate or legally authorized representative signs per state law. Clinician attestation confirming discussion is recommended. In some states a witness or notary signature is also necessary for enforceability.
How do I store and access copies?
Store signed originals in the medical record and maintain encrypted electronic copies with audit trails. Limit access to authorized personnel, retain copies per HIPAA and federal guidance, and ensure portability for transfers between facilities or hospice providers.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now