Can this questionnaire be signed electronically?

Yes. Electronic signatures are generally valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure the transaction meets the four ESIGN validity criteria: intent, consent, attribution, and reproducible record.

Do I need a HIPAA BAA to use an eSignature provider?

If the questionnaire contains protected health information and a vendor will act as a business associate, execute a Business Associate Agreement. HIPAA requirements remain in effect for storage, access, and disclosure of PHI.

When is notarization or witness required?

Notarization and witness needs depend on state law and the document type. Some states require witnesses or notarization for durable power of attorney or advance directives; consult the state notary or statutes for specifics.

Who is authorized to sign on a patient’s behalf?

A legally appointed healthcare proxy or guardian may sign when authorized by statute or valid power of attorney. Absent a proxy, follow state default surrogate rules; document authority clearly to avoid disputes.

How do I update or revoke a completed questionnaire?

Updates should be made via a new signed document referencing the prior version or using an amendment field; revocations should be recorded as a signed revocation document and distributed to relevant providers.

How long should we retain completed questionnaires?

Follow HIPAA retention (45 CFR §164.530(j)) of six years from creation or last effective date and any longer state or industry retention obligations; financial or tax records may have separate periods.

Electronic Signature
Templates
Healthcare
Healthcare Planning Questionnaire

Healthcare Planning Questionnaire

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

HEALTH CARE PLANNING QUESTIONNAIRE

Patient Information

Full Legal Name

Date of Birth

Gender

Address

Phone

Email

Emergency Contact

Name

Relationship

Phone

Insurance Information

Primary Insurer

Policy Number

Group Number

Subscriber Name (if different)

Medical History

Current Medications Allergies / Adverse Reactions Prior Surgeries / Hospitalizations Chronic Medical Conditions Primary Care Provider / Clinic Other Treating Providers

Advance Care Preferences and Values

Describe your overall goals of care, what matters most to you, and outcomes you would find unacceptable. This information guides clinicians when making treatment decisions on your behalf.

Spiritual, Cultural, or Personal Considerations

Specific Treatment Preferences

For each category below, select the option that most closely matches your preference. These selections will be used to inform treatment when you are unable to communicate. If more context is needed, provide additional instructions in the space provided.

Cardiopulmonary Resuscitation (CPR) Attempt resuscitation (CPR) if heart stops Do not attempt resuscitation (DNR)

Mechanical Ventilation (Breathing Machine) Accept use of mechanical ventilation if needed Decline mechanical ventilation

Artificial Nutrition and Hydration Accept tube feeding / IV nutrition Decline long-term artificial nutrition/hydration Additional instructions:

Antibiotics Use antibiotics for treatable infections Limit antibiotics to comfort-directed use

Hospitalization and Intensive Care Prefer full treatment including hospitalization and ICU Prefer comfort-focused care and avoid aggressive interventions

Palliative and Hospice Care Accept palliative or hospice care when prognosis indicates limited benefit from curative treatment

Additional Instructions or Clarifications

Surrogate Decision-Maker

Identify the person who should make decisions on your behalf if you lack capacity. State any limits to their authority.

Name

Relationship

Phone

Address

Existing Legal Documents

Indicate whether you have formally executed documents that further direct care decisions.

I have an advance directive or living will I have a durable power of attorney for health care If yes, provide details or location of documents

Privacy and Authorization

By completing and signing this questionnaire you acknowledge that the information provided will be included in your medical record and used by your health care team to inform treatment consistent with your stated preferences. You may also permit disclosure of these preferences to designated persons.

I acknowledge receipt of privacy information and understand how these planning statements will be used in my care. Authorization to Share Planning Information Authorization Expiration Date

You may revoke this authorization at any time by notifying your health care provider in writing. Revocation will not affect disclosures made prior to receipt of the revocation.

I understand my right to revoke this authorization and my preference statements.

Certification and Signature

I certify that the information provided in this Healthcare Planning Questionnaire accurately reflects my values, goals, and preferences to the best of my knowledge. I understand that these preferences will guide my care but clinical circumstances or applicable law may affect how they are implemented. I may update or revoke this document at any time.

Patient Name:

Relationship (if signed by guardian):

Signature:

Date:

What the Healthcare Planning Questionnaire Is and when it’s used

A Healthcare Planning Questionnaire is a structured form used to capture a patient’s medical preferences, emergency contacts, decision‑maker designations, and key health information for care planning. It consolidates advance directives, proxy appointments, allergy and medication summaries, and HIPAA release preferences so clinicians and administrators have a single, consistent record to guide treatment and care coordination.

Why a clear questionnaire matters for care and compliance

A well‑designed Healthcare Planning Questionnaire reduces ambiguity about patient wishes, improves continuity of care, and supports regulatory compliance such as HIPAA recordkeeping. It also speeds decision making during acute events and documents consent and designate‑of‑authority details required by providers and legal representatives.

Who typically completes and relies on this questionnaire

Typical users include clinical staff, care coordinators, patients and their designated proxies; the form supports both intake and periodic review.

Patients and authorized proxies completing medical preferences and contact details for providers and hospitals.
Primary care clinicians and care managers who use the document to align treatment plans and referrals.
Health system administrators and legal teams that maintain consent and authorization records for compliance.

The questionnaire is intended for both outpatient clinics and inpatient settings and should be accessible to authorized staff under HIPAA.

Stepwise process to complete and record the questionnaire

Follow these sequential steps to collect, verify, and store the completed questionnaire.

01

Prepare Form: Use the latest version and prefill known patient identifiers.
02

Collect Responses: Have patient or authorized proxy complete all required fields.
03

Verify Identity: Match ID or use electronic authentication methods before signing.
04

Store Securely: Save to the EHR and secure document repository with access controls.

Typical digital workflow settings for online completion

Configure these settings when digitizing the questionnaire to ensure secure routing and accurate capture.

Field	Configuration
Signer Order	Allow patient first, then proxy or witness, then clinician acknowledgement.
Authentication Method	Use email plus SMS code or institution SSO for staff signers.
Conditional Fields	Show treatment options only when relevant checkboxes are selected.
Template Library	Version templates for each facility and require template audit trail.

How electronic completion and routing typically work

A standard eSubmission process reduces friction and maintains an audit trail.

Upload: Sender uploads questionnaire PDF or DOCX into the system.
Place Fields: Add signature, date, and checkbox fields where needed.
Invite Signers: Send emails or share signing links to patient and proxy.
Capture Audit Trail: Record IP, timestamp, and authentication method for each signer.

Essential components to include in a professional questionnaire

Design the form to capture the minimum data set clinicians, legal teams, and registrars need to act quickly and lawfully.

Patient Identifiers

Full legal name, date of birth, and medical record number to ensure unambiguous linking to the electronic health record across systems and providers.

Medical Proxy Designation

Name, contact details, relationship, and scope of authority for the appointed decision maker with effective date and any limitations.

Advance Directive Choices

Clear, selectable treatment preferences (resuscitation, ventilation, dialysis) and space for free‑text clarifications to avoid vague instructions.

Allergies and Medications

Current allergies, high‑risk medication list, and critical conditions so emergency staff have immediate access to life‑safety information.

HIPAA Release

Explicit permissions for who may receive protected health information, retention period, and method of disclosure (paper/electronic).

Emergency Contacts

Primary and secondary contacts with relationship and phone numbers to enable timely family notification during urgent events.

Core privacy and security considerations for this questionnaire

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

Access Controls: Role‑based permissions for clinical and administrative staff

BAA Availability: Business Associate Agreement required for HIPAA workloads

Audit Trail: Detailed signer logs and timestamps

Multi‑factor Auth: Optional two‑factor authentication for high‑risk signers

Retention Controls: Configurable retention and secure deletion policies

Supporting documents commonly submitted with the questionnaire

Attach these documents to provide context and legal proof where required.

Advance Directive

A signed and dated advance directive or living will that expands on treatment preferences and can be relied on by clinicians when the questionnaire indicates such directives exist.

Durable Power of Attorney

A durable power of attorney for healthcare naming the surrogate decision maker, showing authority and any limitation clauses relevant to the questionnaire entries.

Photo ID

Government‑issued photo identification for identity verification at signing; required for notarization or remote identity proofing.

Medical Records Summary

A concise summary of key diagnoses, recent procedures, and current medications to accompany the questionnaire for handoffs.

Delivery and integration options for secure sharing

Choose a platform that supports secure delivery, common integrations, and accepted file formats to reduce operational friction.

Integrations: Salesforce | Microsoft 365 | NetSuite | Google Workspace
File Formats: PDF, DOCX, HTML, Excel
Storage: Box | Google Drive | AWS | Egnyte

Confirm the chosen service supports HIPAA workflows, audit logs, and your institution’s retention and export requirements before enabling live use.

Timing and review expectations for completed questionnaires

Establish clear review and update intervals to keep patient instructions current and actionable.

Provide Upon Request:

Questionnaire should be made available to the patient or proxy when requested, with identity verification.

Initial Entry Timing:

Collect at intake or first clinical visit to ensure decisions are recorded early.

Annual Review:

Recommended yearly review or sooner after major health changes or legal events.

Notarization Timing:

If notarization is required, complete it at signing to avoid later challenges to validity.

HIPAA Retention:

Retain according to 45 CFR §164.530(j) — six years from creation or last effective date.

Key milestones from draft to secure storage

A phased milestone view helps track progress and responsibilities for each stage of completion.

01

Drafting

Prepare and version the questionnaire template with clinical and legal input.

02

Patient Completion

Patient or proxy fills required fields and selects preferences.

03

Verification

Verify identity, witness or notary needs, and authentication method.

04

Storage and Access

Save to EHR and document repository with audit and access controls.

Common preparation mistakes to avoid

Incomplete fields: leaving proxy or emergency contact fields blank creates delays in urgent care decision making and discharge planning.
Ambiguous language: vague instructions like 'no heroic measures' can be interpreted inconsistently across clinicians and settings.
Mismatched names or IDs: inconsistent patient identifiers can prevent matching to the correct medical record or insurance claims.
Improper witness or notarization: skipping required witness or notary steps in jurisdictions that require them can render the document legally ineffective.

Risks and potential consequences of an incorrect or incomplete questionnaire

Invalid Proxy: Patient decisions may be overturned if the proxy designation is legally deficient

HIPAA Exposure: Improper disclosures risk regulatory enforcement and breach notifications

Delayed Care: Ambiguous or missing preferences can delay urgent treatment decisions

Legal Challenge: Family disputes may lead to probate or court involvement

Notarization Error: Missing or incorrect notarization may void statutory forms

Record Mismatch: Data errors can cause billing or insurance claim denials

Representative eSignature vendor pricing and capability snapshot

This vendor comparison highlights starting price and core capabilities relevant to healthcare workflows; verify vendor plans for enterprise add‑ons and HIPAA terms.

	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	Yes — vendor trial varies	Yes — vendor trial varies	Yes — vendor trial varies	Yes — vendor trial varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Real organization examples showing digital form use

Organizations across sectors use digital questionnaires and eSign workflows to standardize intake, speed responses, and maintain secure records.

Fertility Centers of Illinois

Needed reliable online forms for patient intake to reduce administrative backlog.

Used an integrated eSignature workflow to collect signatures and HIPAA authorizations.
"The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Optica Ventures LLC

Required a simple, mobile friendly approach to capture client consent remotely.

Adopted templated questionnaires and mobile signing for onsite and offsite collection.
"The interface is simple and easy‑to‑use for our team; more importantly, it is just as easy for our customers."

Practical tips to ensure accuracy and legal robustness

Adopt these best practices to reduce downstream risk and administrative overhead.

Standardize Templates and Versions

Maintain a single approved template per facility, track version history, and require legal sign‑off for substantive wording changes to avoid inconsistent obligations.

Use Strong Authentication

Require SMS codes or institutional SSO for proxies and staff; use remote identity proofing for notarized or high‑risk authorizations.

Document Revocation Process

Specify how a patient can revoke or update preferences, the required format for revocation, and how the organization will confirm and record the change.

Train Staff and Monitor Compliance

Provide staff training on required fields, witness/notary procedures, and privacy safeguards; audit completion rates and follow up on missing information.

Frequently asked questions about using the Healthcare Planning Questionnaire

Answers to typical operational and legal questions encountered when implementing and maintaining these questionnaires.

Need help? Contact support

Can this questionnaire be signed electronically?
Yes. Electronic signatures are generally valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure the transaction meets the four ESIGN validity criteria: intent, consent, attribution, and reproducible record.
Do I need a HIPAA BAA to use an eSignature provider?
If the questionnaire contains protected health information and a vendor will act as a business associate, execute a Business Associate Agreement. HIPAA requirements remain in effect for storage, access, and disclosure of PHI.
When is notarization or witness required?
Notarization and witness needs depend on state law and the document type. Some states require witnesses or notarization for durable power of attorney or advance directives; consult the state notary or statutes for specifics.
Who is authorized to sign on a patient’s behalf?
A legally appointed healthcare proxy or guardian may sign when authorized by statute or valid power of attorney. Absent a proxy, follow state default surrogate rules; document authority clearly to avoid disputes.
How do I update or revoke a completed questionnaire?
Updates should be made via a new signed document referencing the prior version or using an amendment field; revocations should be recorded as a signed revocation document and distributed to relevant providers.
How long should we retain completed questionnaires?
Follow HIPAA retention (45 CFR §164.530(j)) of six years from creation or last effective date and any longer state or industry retention obligations; financial or tax records may have separate periods.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now