Can this be signed electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act and most states’ UETA statutes when intent and consent are present. For healthcare consumer-facing records, provide the required ESIGN consumer disclosure and ensure the record can be retained and reproduced.

Is a notary or witness required?

Requirements vary by state and by the document’s intended legal use. Some states require witnesses or notarization for surrogate designations or durable authority. Confirm the jurisdictional rule before finalizing.

How do I change the document later?

Create a new dated version and indicate supersession of prior versions. Record signer and clinician names, timestamps, and maintain prior versions for the audit trail.

Who should sign if the patient lacks capacity?

A legally authorized surrogate or agent with decision-making authority signs on behalf of the patient, consistent with state law and any existing power of attorney or guardianship documents.

How do I ensure HIPAA compliance?

Use a platform that supports a Business Associate Agreement, encrypts data in transit and at rest, and maintains detailed audit logs of access and signature events.

What happens if the form conflicts with an advance directive?

Clarify which document the patient designates as controlling; if unclear, clinicians should follow the most recently executed document or consult legal counsel when conflicts arise.

Electronic Signature
Templates
Healthcare
Healthcare Values Exploration

Healthcare Values Exploration

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

Healthcare Values Exploration

Purpose: This document is intended to record the patient's personal values, priorities, and preferences regarding medical care to inform future clinical decision-making. It is a voluntary, interpretive statement to guide clinicians and surrogate decision-makers. It is not, by itself, a binding advance directive but may be included in the medical record and considered alongside any legal directives or proxy appointments.

PATIENT INFORMATION

Patient Name:

Date of Birth

Gender

Address

Primary Phone

EMERGENCY & PROXY CONTACTS

Emergency Contact

Health Care Proxy / Agent (if appointed)

INSURANCE & CLINICAL SUMMARY

Primary Insurance Provider

Policy / Group Number

MEDICAL HISTORY / CURRENT HEALTH

Current Medications Allergies / Adverse Reactions Significant Past Surgeries / Conditions Current Diagnosis / Prognosis (as understood)

VALUES, GOALS, AND PRIORITIES

Describe what matters most to you when considering medical care (examples: length of life, independence, comfort, cognition, ability to communicate, time with family). Use specific examples where possible.

Rank the following priorities from 1 (most important) to 5 (least important) by entering numbers in the boxes.

Independence / Ability to live at home Comfort / Symptom control Length of life Cognitive function / Awareness Time with family / Social participation

TREATMENT PREFERENCES — GENERAL

Indicate your general preferences. Check only those that reflect your values; leave blank those where you want clinicians to use professional judgment or consult your proxy.

Attempt cardiopulmonary resuscitation (CPR) if heart stops
Accept intubation and mechanical ventilation
Accept tube feeding (enteral nutrition)
Accept dialysis for kidney failure
Accept antibiotics for severe infections
Prefer comfort-focused care only (no aggressive life-prolonging interventions)

If you checked any preferences above, please clarify circumstances, goals, or time-limits for those choices (for example, willing to accept ventilation for a defined recovery period)

ACCEPTABLE AND UNACCEPTABLE OUTCOMES

Outcomes I would FIND ACCEPTABLE Outcomes I would FIND UNACCEPTABLE

SPIRITUAL, CULTURAL, AND PERSONAL CONSIDERATIONS

Religious / Spiritual Beliefs or Cultural Factors Preferred Care Setting

COMMUNICATIONS AND DECISIONAL GUIDANCE

Guidance to clinicians and proxy: In situations where treatment decisions must be made, I prefer that my health care team and my appointed decision-maker:

Prioritize quality of life and comfort
Prioritize life extension when there is reasonable chance of recovery
Follow explicit wishes recorded here and in my advance directive
Seek input from family and loved ones when values are unclear

Other guidance for decision-makers

CONFIDENTIALITY, AUTHORIZATION AND EFFECTIVENESS

Confidentiality: Information recorded in this form will be included in the medical record and kept confidential in accordance with applicable health information privacy laws. Authorization: By signing, the patient confirms that the information is an accurate expression of personal values and preferences and authorizes inclusion of this document in the medical record. Revocation: The patient may revoke or amend this document at any time by submitting a revised statement to the care team.

Effective Date of this Statement

Expiration / Review Date (optional)

ACKNOWLEDGMENT

By signing below, I acknowledge that: (1) I have had the opportunity to discuss my values and preferences with my care team; (2) this document reflects my personal values and treatment preferences as of the Effective Date; (3) I understand this document is intended to guide clinical decision-making and is not, by itself, a legal substitute for an advance directive or appointment of a health care agent, except where recognized by law; and (4) I may amend or revoke this document at any time.

Patient Name:

Signature:

Date:

Relationship to patient (if signing as guardian or agent)

If signing as an agent or guardian, authority to sign (include document type and date)

What the Healthcare Values Exploration Is and When It Helps

A Healthcare Values Exploration is a structured document that records a patient’s priorities, goals, and preferences for medical care. It typically gathers values statements, trade-offs the patient is willing to accept, preferred quality-of-life outcomes, and designated decision-makers. Clinicians, care teams, patients, and surrogates use it to guide treatment planning when clinical decisions require alignment with personal values. The form complements advance directives and clinical notes by translating abstract preferences into actionable guidance for routine care, crisis situations, and care transitions.

Why documenting values matters in clinical decision-making

Capturing patient values reduces ambiguity during urgent decisions, supports shared decision-making, and creates a consistent record clinicians can reference across care settings and transitions.

Who typically completes and relies on this document

The Healthcare Values Exploration is completed by patients with clinician support or by authorized surrogates when patients lack capacity.

Primary clinicians and care teams who use the documented values to align treatment plans and orders.
Patients and legally authorized surrogates who state preferences and designate decision-makers.
Care coordinators or case managers who distribute and archive the completed exploration across care settings.

Clear documentation ensures continuity of care and reduces conflict by making preferences available to all treating providers.

Step-by-step: completing a Healthcare Values Exploration

Follow these steps to prepare, complete, and distribute the exploration so it informs care promptly and reliably.

01

Prepare: Gather patient identifiers, current meds, and recent clinical notes.
02

Discuss: Clarify values and scenarios with patient or surrogate in plain language.
03

Document: Complete fields accurately and record trade-offs and decision-makers.
04

Distribute: Add to the EHR, share with care team, and provide a copy to the patient or surrogate.

Digital delivery options and system requirements

The Healthcare Values Exploration can be completed on paper or via secure digital platforms that support eSignature and protected data handling.

File formats: PDF, DOCX, and structured form exports supported.
Integrations: Common integrations include EHR connectors and cloud storage.
Authentication: Email, SMS code, or stronger multi-factor methods available.

Choose a platform with HIPAA controls and audit logs to maintain confidentiality and a clear record of consent and changes.

Typical electronic workflow for completion and sharing

A common eSubmission flow reduces paper handling while preserving legal integrity and auditability.

Upload: Sender uploads template and pre-fills patient identifiers.
Assign: Place fields and assign signers or allow guest signing.
Sign: Signer authenticates and signs electronically.
Archive: Signed copy and audit trail stored in the record.

Essential components included in a professional exploration

A complete document blends structured prompts with space for narrative, legal designations, and versioning to support clinical and legal use.

Values Inventory

Structured prompts that help patients prioritize outcomes such as comfort, independence, and longevity, with examples to reduce ambiguity.

Prioritization Matrix

A simple ranked list or matrix that clarifies which goals take precedence when conflicts arise during care decisions.

Narrative Section

Open-text area for personal statements and explanatory context clinicians can reference in complex cases.

Decision Proxy

Designation of surrogate or agent with contact details, scope of authority, and any conditional instructions for activation.

Version History

Visible record of updates, reviewer names, and timestamps so clinicians see the most recent preferences.

Export Options

PDF and structured data exports enable attachment to the EHR and secure sharing across care sites.

Configuring an electronic workflow for this form

Set up authentication, routing, and storage before sending to ensure legal compliance and clinical accessibility.

Workflow Setting	Configuration
Authentication Method	Email link, SMS code, or multi-factor
Field Permissions	Read-only for clinicians, editable for patient
Routing Order	Patient or surrogate signs first, clinician countersigns
Storage Location	EHR document folder and secure archive

Key timing expectations and review intervals

Establish and communicate timelines for review, update, and clinical incorporation to keep values current and actionable.

Initial Completion:

Complete during a dedicated session or outpatient visit; typical target within 7 days of decision.

Clinical Review:

Clinician reviews exploration at each major care transition or hospital admission.

Annual Update:

Recommend formal review at least once every 12 months or after major health changes.

Immediate Revisit:

Update promptly when a patient’s prognosis or treatment options change significantly.

Processing Time:

Digital signatures complete immediately; distribution typically within 24 hours.

Milestones from preparation to long-term storage

Track these stages to ensure the exploration is actionable, audited, and retained according to policy.

01

Preparation

Collect identifiers, medical context, and legal agent details before discussion.

02

Patient Discussion

Clarify priorities, trade-offs, and decision thresholds with the patient or surrogate.

03

Documentation

Record values, obtain signatures, and capture version and timestamp.

04

Distribution and Archival

Add to EHR, share with care team, and retain per retention policy.

Security and privacy controls to look for

Encryption: AES-256 at rest

Transport Security: TLS 1.2/1.3 in transit

Access Logs: Detailed audit trail

BAA Requirement: Business Associate Agreement available

Authentication: Multi-factor options

Compliance: HIPAA and SOC 2 controls

Common legal and clinical risks to avoid

HIPAA Breach: Significant fines and corrective actions

Invalid Consent: Undue ambiguity can void decisions

Misidentification: Wrong patient records cause wrong-care risk

Missing Witness: Some states require witnesses for certain forms

Data Loss: Loss of audit trail undermines evidentiary value

Late Updates: Outdated preferences may conflict with current care

Frequent preparation and completion mistakes

Using vague language for priorities that leaves clinicians unsure how to act in nuanced scenarios.
Mismatched names or identifiers that prevent the document from being linked reliably in the electronic health record.
Failing to record the signer’s capacity or the surrogate’s legal authority, which can lead to disputes.
Skipping version history or timestamps, making it hard to know which document is current after revisions.

Comparing eSignature vendor pricing and key capabilities

High-level pricing and capability markers to consider for signing and distributing Healthcare Values Exploration forms; vendor plans and features vary by billing model 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 credit card	Varies by plan	Varies by plan	Varies by plan	Varies by plan
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 Values Exploration

Answers to common legal, technical, and clinical questions about completing, signing, and updating the document.

Need help? Contact support

Can this be signed electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act and most states’ UETA statutes when intent and consent are present. For healthcare consumer-facing records, provide the required ESIGN consumer disclosure and ensure the record can be retained and reproduced.
Is a notary or witness required?
Requirements vary by state and by the document’s intended legal use. Some states require witnesses or notarization for surrogate designations or durable authority. Confirm the jurisdictional rule before finalizing.
How do I change the document later?
Create a new dated version and indicate supersession of prior versions. Record signer and clinician names, timestamps, and maintain prior versions for the audit trail.
Who should sign if the patient lacks capacity?
A legally authorized surrogate or agent with decision-making authority signs on behalf of the patient, consistent with state law and any existing power of attorney or guardianship documents.
How do I ensure HIPAA compliance?
Use a platform that supports a Business Associate Agreement, encrypts data in transit and at rest, and maintains detailed audit logs of access and signature events.
What happens if the form conflicts with an advance directive?
Clarify which document the patient designates as controlling; if unclear, clinicians should follow the most recently executed document or consult legal counsel when conflicts arise.

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