Can the booklet be signed electronically?

Yes. Electronic signatures are enforceable under the federal ESIGN Act (15 U.S.C. ch. 96) and most state UETA statutes, provided the signature demonstrates intent, consent, attribution, and the record is retained. Check for any state-specific exceptions before relying on e-signature alone.

Does HIPAA affect sharing directives?

Yes. Copies containing protected health information must be transferred and stored in compliance with HIPAA; a business associate agreement may be required when a vendor handles PHI (see 45 CFR §164.502).

What if signatures are missing witnesses?

Missing required witnesses or notarization can impair enforceability under state law and may require court proceedings to validate the document. Where possible, re-execute with proper formalities.

Can an agent refuse to serve?

Yes. Many states require the agent to sign or otherwise accept appointment to demonstrate consent; refuse or absence of acceptance may require successor appointment.

How should providers verify authenticity?

Providers should check identity, witness/notary blocks, and any audit trail for electronic signatures. Notarized or self-proved affidavits reduce the need for witness testimony at probate.

How do I revoke the booklet?

A principal may revoke directives at any time while competent by destroying the document, signing a revocation, notifying the agent, or executing a new directive; follow state statute for formal revocation methods.

Electronic Signature
Templates
Healthcare
Healthcare Directives Booklet

Healthcare Directives Booklet

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

Healthcare Directives Booklet

Patient Information

Patient Name

Date of Birth: Gender:

Address

Phone: Email:

Emergency Contact

Name

Relationship: Phone:

Insurance Information

Primary Insurer

Policy Number: Group Number:

Subscriber Name

Medical History (Brief)

Current Medications Allergies Prior Surgeries / Hospitalizations Chronic Conditions

Designation of Health Care Agent

I hereby designate the following person to make health care decisions on my behalf when I am unable to make or communicate decisions for myself. This designation grants the agent broad authority to make all health care decisions, including decisions about life-sustaining treatment, hospitalization, and access to medical records, consistent with the instructions below.

Primary Health Care Agent — Name

Relationship: Phone:

Address

Alternate Agent

Alternate Agent — Name

Relationship: Phone:

Scope and Effect of Agent Authority

Agent Authority: The agent is authorized to consent to or refuse any care, treatment, service or procedure to maintain, diagnose, or treat a physical or mental condition. This includes, but is not limited to, authority relating to cardiopulmonary resuscitation, mechanical ventilation, tube feeding, dialysis, surgery, antibiotics, psychiatric medication, and palliative care. The agent shall have access to and control over my medical records to the extent permitted by law.

Durability: This designation is effective immediately and shall not be affected by my subsequent incapacity unless I specifically designate a different effective condition below.

Effective Condition: Effective immediately Effective upon my incapacity as determined by two physicians or the attending physician and one licensed mental health professional

Life-Sustaining Treatment Preferences

Resuscitation: Full code — attempt all resuscitative measures
Do Not Resuscitate (DNR) — do not perform cardiopulmonary resuscitation
Limited interventions as further described in specific instructions below

Life-Sustaining Treatments (check any that you specifically refuse):
Mechanical ventilation
Artificial nutrition and hydration (tube feeding)
Dialysis

Additional Instructions or Clarifications

Pain Management and Comfort Care

I request that measures be taken to provide comfort and pain relief under all circumstances, even if such measures may hasten the moment of death, according to the standards of palliative medicine and my expressed preferences below.

Comfort Care Preferences

Organ and Tissue Donation

Upon my death I direct the following (check all that apply):

Donate any organs or tissue suitable for transplantation or research
Donate only the following organs/tissues:
Do not donate organs or tissues

HIPAA Privacy Authorization

I authorize the release of my protected health information to the health care agent named above, to the extent necessary for the agent to carry out the powers granted in this document. This authorization includes medical records, test results, and communications by electronic or paper means. It is intended to satisfy applicable law permitting access by an agent under an advance directive.

Expiration of HIPAA Authorization:

Revocation and Amendment

Revocation: I may revoke or amend this document at any time by providing written notice to my health care provider, my designated agent, or by physically destroying a signed copy. Any such revocation or amendment should be communicated promptly to my health care providers and my agent.

Witness Attestation

The undersigned witnesses declare that the principal appears to be of sound mind, free from duress, fraud or undue influence, and signed or acknowledged this document in the presence of the witnesses. A witness must not be: (a) the designated health care agent or alternate; (b) a spouse or domestic partner; (c) a direct heir or beneficiary under the principal's estate; or (d) the attending physician.

Witness 1 — Printed Name

Address:
Witness 1 Signature: Date:

Witness 2 — Printed Name

Address:
Witness 2 Signature: Date:

Acknowledgment and Certification

I certify that I understand the nature and effect of this document, that I am emotionally and mentally competent to make these decisions, and that I sign this advance directive of my own free will. I understand that my health care providers and institutions may rely upon this document in making treatment decisions on my behalf.

If signing as legal guardian or authorized representative, indicate capacity:

Patient:

By:

Date:

What the Healthcare Directives Booklet Is and what it includes

The Healthcare Directives Booklet is a consolidated packet that records a person’s advance healthcare directives, including a durable power of attorney for health care (healthcare proxy or agent), living will instructions, organ donation preferences, and any applicable treatment limitations. It standardizes fields for identity, agent designation, scope of authority, effective date, and signatures so clinicians and surrogates can quickly find legally actionable instructions. The booklet is intended for use in clinical settings, long-term care, and by family members making decisions when a patient lacks capacity.

Why a standardized Healthcare Directives Booklet matters

A clear, consistent booklet reduces ambiguity at critical moments, helps ensure that patient wishes are respected, and centralizes the information clinicians and authorized agents need. It supports continuity of care and can streamline administrative steps during admission or transfer.

Who typically completes or receives the booklet

The Healthcare Directives Booklet is completed by adults, their designated agents, and sometimes by legal advisors when formal review is required.

Patients and competent adults who wish to document treatment preferences and appoint a healthcare agent.
Designated agents or healthcare proxies who accept decision-making responsibilities for the patient.
Clinicians and facility intake staff who must verify directives during admission or care transitions.

Health systems, primary care providers, long-term care facilities, and family members use the booklet to confirm decision-making authority and treatment preferences.

Who has legal authority to sign

Designated Agent

Designated agent — Health Care Agent. The designated healthcare agent is the person named to make medical decisions if the principal loses capacity. The agent’s authority is determined by the booklet’s scope language and applicable state law; many states require agent acceptance and clear signature to evidence consent.

Principal

Principal — Individual creating directives. The principal must have capacity when signing; their handwritten or electronically executed signature establishes intent and consent. If incapacity occurs later, the agent acts under the executed directives and any statutory requirements for witnessing or notarization under state law.

Core sections you should expect in the booklet

A professional Healthcare Directives Booklet groups essential elements into discrete sections to reduce confusion and support enforceability across providers and states.

Identity Block

Full legal name, date of birth, and government ID details so providers can match records and avoid misidentification during urgent care or electronic record lookup.

Agent Designation

Primary agent name, contact information, relationship to the principal, and successor agents; clearly states the scope and activation conditions for surrogate decision making.

Treatment Preferences

Specific instructions about life-sustaining treatment, resuscitation, mechanical ventilation, artificial nutrition or hydration, and pain management preferences where applicable.

Organ Donation and Other Authorizations

Organ/tissue donation choices and any limited authorizations for anatomical gift, research participation, or the release of medical records for continuity of care.

Signatures and Dates

Principal signature, date, witness signatures or notary acknowledgment as required by state law, and agent acceptance signature when applicable.

Emergency Access Notes

Instructions for where the original is stored, how to access electronic copies, and contact points for verifying authenticity in emergencies.

Step-by-step: completing and activating the booklet

Follow these steps in order to create a legally effective and accessible Healthcare Directives Booklet.

01

Prepare Identity: Enter full legal name and DOB.
02

Name Agents: Designate primary and alternate agents.
03

Specify Preferences: Record clear treatment instructions.
04

Execute Properly: Sign with required witnesses or notary.

How the completed booklet is used by providers and agents

This process explains typical routing from completion to clinical use and archival storage.

Upload or File: Copy uploaded to EHR or given to agent.
Verify Identity: Provider confirms identity and signatures.
Activate Agent: Agent acceptance recorded when required.
Apply Preferences: Clinical teams follow documented directives.

Typical digital workflow settings for eCompleting the booklet

Recommended configuration settings when deploying the booklet in an eSignature or EHR-integrated workflow.

Field	Configuration
Signer Order	Sequential or parallel as required
Authentication	Email link with optional SMS code
Retention Policy	Retain electronic copy minimum term
Notifications	Enable signer and admin alerts

Technical considerations for digital completion and storage

Select a platform that supports secure access, audit trails, and the file formats your health system uses.

File formats: PDF, DOCX supported
Integrations: EHR, Google Workspace, NetSuite
Security: AES-256 at rest

Review, update, and re-execution timelines

The booklet should be reviewed and re-signed after key events to ensure current wishes and valid authorization.

Annual Review Recommended:

Review preferences yearly or after health changes.

After Major Health Event:

Update directives following diagnosis or hospitalization.

Change of Agent:

Execute a new booklet when replacing an agent.

Relocation Across States:

Review for state-specific requirements after moving.

Provider Request:

Re-sign if a facility requests updated documentation.

Common mistakes to avoid when preparing the booklet

Using ambiguous phrases for life-sustaining treatment choices that leave interpretation to clinicians or courts.
Failing to include successor agents, which can create gaps if the primary agent is unavailable.
Signing without required witnesses or notarization under state law, risking invalidation during probate or clinical review.
Storing the only copy in a place inaccessible to agents or treating clinicians during an emergency.

Potential legal consequences and risks

Invalid Execution: May invalidate directives

Disputed Authority: Agent decisions challenged

Care Delays: Treatment postponed pending verification

Criminal Risk: Unauthorized decisions risk liability

HIPAA Violations: Improper disclosures attract penalties

Civil Exposure: Family litigation or damages

Essential data elements and security markers

Patient ID: Full name & DOB

Agent Contact: Phone and mailing address

Scope Flags: Treatment limits coded

Execution Date: Signed MM/DD/YYYY

Witness/Notary: Signature details recorded

Storage Note: Location of originals

Representative eSignature pricing and capability comparison

Baseline pricing and common capability indicators for major eSignature vendors. Confirm vendor plans directly for plan-specific limits and add-ons.

	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	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Available (Business Premium)	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA required)	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Real-world examples of booklet use

These case snapshots show practical outcomes when organizations standardize healthcare directives.

Fertility Centers of Illinois

A regional clinic standardized directives to reduce intake delays and confusion.

Staff reported faster verification and fewer missing agent contacts.
Management noted improved patient satisfaction because copies were accessible electronically and portable across clinics.

Martin Properties

A property manager kept resident directives on file for assisted-living units.

Quick access reduced emergency transfers and clarified agent authority.
The facility avoided conflicting instructions during three separate admissions when directives were immediately available to nursing staff.

Notarization and witness execution steps

Follow these eight steps when executing notarized or witnessed directives to satisfy typical state formalities and evidentiary needs.

01

Confirm Capacity

Ensure the principal has decision-making capacity at signing.

02

Select Execution Method

Choose RON or in-person notarization based on state allowance.

03

Identity Proofing

Use government ID and identity-verification methods where required.

04

Witness Presence

Arrange required number of witnesses per state rules.

05

Agent Acceptance

Have agent sign acceptance if the jurisdiction requires it.

06

Notary Acknowledgment

Notary completes journal entry and acknowledgement block.

07

Record Audio/Video

For RON, retain required audio-video session recording.

08

Distribute Copies

Provide copies to agent, clinicians, and file originals securely.

Practical tips for accurate and efficient completion

Adopt these practices to reduce errors, support enforceability, and keep records accessible to authorized parties.

Use plain unambiguous language

Avoid subjective phrases; state clear preferences (for example, 'Do not intubate' rather than 'prefer not to be kept alive artificially').

Provide complete contact details

Include phone numbers, emails, and mailing addresses for agents and alternates so providers can confirm authority quickly during an emergency.

Maintain an executed original

Keep one original signed document in a secure, accessible location and provide certified copies to agents and primary clinicians.

Periodically verify

Review directives after health changes, major life events, or interstate moves to ensure compatibility with current state rules and personal wishes.

Frequently asked questions and practical answers

Answers to common questions about execution, validity, digital signing, and what to do if disputes arise.

Need help? Contact support

Can the booklet be signed electronically?
Yes. Electronic signatures are enforceable under the federal ESIGN Act (15 U.S.C. ch. 96) and most state UETA statutes, provided the signature demonstrates intent, consent, attribution, and the record is retained. Check for any state-specific exceptions before relying on e-signature alone.
Does HIPAA affect sharing directives?
Yes. Copies containing protected health information must be transferred and stored in compliance with HIPAA; a business associate agreement may be required when a vendor handles PHI (see 45 CFR §164.502).
What if signatures are missing witnesses?
Missing required witnesses or notarization can impair enforceability under state law and may require court proceedings to validate the document. Where possible, re-execute with proper formalities.
Can an agent refuse to serve?
Yes. Many states require the agent to sign or otherwise accept appointment to demonstrate consent; refuse or absence of acceptance may require successor appointment.
How should providers verify authenticity?
Providers should check identity, witness/notary blocks, and any audit trail for electronic signatures. Notarized or self-proved affidavits reduce the need for witness testimony at probate.
How do I revoke the booklet?
A principal may revoke directives at any time while competent by destroying the document, signing a revocation, notifying the agent, or executing a new directive; follow state statute for formal revocation methods.

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