Establishing secure connection…Loading editor…Preparing document…

Healthcare Preferences Form

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

HEALTHCARE PREFERENCES FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Healthcare Decision-Maker (Proxy) Preferences

Preferred Healthcare Proxy Name:

Relationship:    Phone:

Scope of Proxy Authority (check all that apply)





Treatment Preferences

Resuscitation preference (select one):


Mechanical ventilation if unable to breathe on own:



Artificial nutrition and hydration if unable to eat or drink:



Antibiotics for life-threatening infections:


Pain Management & Comfort Care

Organ Donation


HIPAA & Privacy Acknowledgment

I acknowledge that my healthcare providers may share medical information as reasonably necessary to honor these healthcare preferences and to permit my designated proxy to make decisions on my behalf. I understand that this authorization is limited to the purposes set forth in this document.

Authorization, Duration, and Revocation

This document expresses my current healthcare preferences and authorizations. I understand these preferences will guide healthcare providers and my designated proxy. I further understand that I may revoke or amend this form at any time by providing written notice to my healthcare provider or by executing a superseding written document. Such revocation is effective upon receipt by my provider, except to the extent actions have already been taken relying on this document.

Certification

I certify under penalty of perjury that the information provided in this Healthcare Preferences Form is true and correct to the best of my knowledge. I understand that healthcare providers will make reasonable efforts to follow these instructions. By signing below I affirm that I am competent to make these decisions, or, if signing as a legal representative, that I have the lawful authority to sign on behalf of the patient and will provide documentation upon request.

Patient Name:

Signature:

Date:

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Healthcare Preferences Form Is and when it applies

A Healthcare Preferences Form documents an individual’s treatment choices, surrogate decision-maker, and comfort-care preferences for use by clinicians and caregivers. It typically records preferences for life-sustaining treatment, resuscitation, artificial nutrition, pain management, and organ donation. The form can be used at hospital admission, during long-term care placement, or as part of advance care planning. When combined with a legally recognized advance directive or power of attorney, it helps ensure clinical teams follow the patient’s expressed wishes across care settings.

Why completing a Healthcare Preferences Form matters

Documenting healthcare preferences clarifies treatment goals, reduces conflicts among family and providers, and supports person-centered care. It preserves the patient’s voice when they cannot speak for themselves and helps clinicians make medically appropriate decisions that reflect those values.

Why completing a Healthcare Preferences Form matters

Who commonly completes or relies on this form

Keeping the form current and accessible ensures it is followed across outpatient visits, hospital stays, and emergency care.

  • Patients with chronic or life-limiting conditions who want to record specific treatment limits or goals.
  • Designated healthcare agents or surrogates who need a clear statement of the patient’s wishes.
  • Healthcare organizations and clinicians who require documented guidance for treatment decisions.

Core components to include in a professional form

A complete Healthcare Preferences Form combines identity details, specific treatment choices, decision-maker designation, signature blocks, effective dates, and consent for information sharing.

Patient Identity

Full legal name, date of birth, and contact information to match medical records and avoid identity confusion.

Treatment Choices

Clear yes/no choices for resuscitation, intubation, artificial nutrition, hydration, antibiotics, and comfort-only measures to guide clinicians.

Decision-Maker

Name and contact of the appointed healthcare agent or surrogate with scope of authority and relationship to the patient.

Signature & Date

Signature of the patient or authorized representative with date and witness/notary details when required by state law.

Effective Period

Specify when the form takes effect and whether it supersedes prior directives to avoid conflicting instructions.

Information Sharing

Consent language that permits sharing the form across treating providers and with emergency services when clinically relevant.

Security and compliance essentials to protect preferences

HIPAA: BAA required
Encryption: TLS 1.2/1.3
Data at Rest: AES-256
Audit Trail: Timestamped events
Authentication: Multi-factor options
Regulatory Fit: ESIGN/UETA compliant

Step-by-step: completing the Healthcare Preferences Form

Follow these steps to complete and validate the form so it is accepted by clinical teams and integrated into the health record.

  • 01
    Collect Patient Details: Enter name, DOB, and contact information.
  • 02
    Record Preferences: Select clear options for life-sustaining treatments.
  • 03
    Designate Surrogate: Name primary and alternate decision-makers.
  • 04
    Sign and Date: Sign in full and add witness or notary if required.

How the form moves through clinical workflows

A standard workflow routes the completed form to the chart, notifies care teams, and updates advance care planning flags.

  • Submission: Form is provided at intake or uploaded to the patient record.
  • Review: Clinician confirms preferences and documents any clinical contraindications.
  • Storage: Form is stored in the EHR and scanned for quick access.
  • Notification: Relevant caregivers and surrogate receive confirmation of record update.

Configuring an electronic workflow for the form

Key configuration choices affect authentication, routing, and record retention for e-submission.

Field Configuration
Signature Method E-signature with audit trail and optional PKI
Authentication Level Email plus SMS code for signer verification
Conditional Fields Show surrogate block only if patient designates agent
Retention Setting Attach to EHR with 7+ year archive

Technical requirements for secure eSubmission

Verify business associate agreements and audit trail retention policies with your platform vendor before using electronic signatures in clinical settings.

  • File Formats: PDF and DOCX supported
  • Integrations: Supports EHR and cloud storage
  • Authentication: SMS, SSO, or KBA

Timing considerations and review windows

Certain events trigger completion or review of the Healthcare Preferences Form; align timing with clinical and legal requirements.

At Admission:

Complete or confirm preferences during initial intake.

On Transfer:

Update form when moving between care settings.

Annual Review:

Review preferences at least once per year or after major changes.

After Diagnosis Change:

Revisit form when prognosis or treatment options change.

Upon Major Life Event:

Update after marriage, divorce, or change in decision-maker.

Penalties and risks of inaccurate or mishandled forms

HIPAA Violation: Civil fines possible
Invalid Instructions: Clinicians may disregard unclear choices
Delayed Care: Ambiguity can slow urgent decisions
Insurance Issues: Coverage disputes for treatment choices
Legal Challenge: Surrogate disputes or probate risk
Data Breach: Potential state penalty exposure

Common mistakes to avoid when preparing the form

  • Leaving treatment choices vague or conditional, which can result in conflicting interpretations at the bedside.
  • Failing to name an alternate surrogate, causing decision delays if the primary agent is unavailable.
  • Not dating or signing the form correctly, which can render the document unenforceable by providers.
  • Storing the form only in paper without scanning it into the EHR, reducing accessibility during emergencies.

How this form compares with other advance care documents

Compare the Healthcare Preferences Form with more formal legal documents to choose the correct instrument for your needs.

Criteria Healthcare Preferences Form Advance Directive
Legal Weight guiding document statutory legal effect
Complexity simple checklist detailed legal language
Notarization usually optional often recommended or required
Use Case clinical guidance durable legal instruction

Sample eSignature vendor comparison for handling Healthcare Preferences Forms

Comparing common vendor features and starting price helps select a compliant signing platform; signNow appears first per data available.

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 Yes, 7-day trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about Healthcare Preferences Forms

Answers to common questions about legal effect, signatures, and updates when using a Healthcare Preferences Form.


Need help? Contact support

be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.