Can I sign this form electronically?

Yes, electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA in most states, provided the platform demonstrates intent, consent, attribution, and record retention. Confirm devices and authentication meet any state-specific witness or notary requirements.

Is the form HIPAA-compliant when sent digitally?

Digital transfer must preserve privacy under HIPAA. Use a HIPAA-compliant platform and Business Associate Agreement if a third party handles protected health information; otherwise, avoid unsecured email for patient directives.

Do I need witnesses or a notary?

Witness and notary requirements vary by state. Some states require two witnesses or notarization for advance directives; others do not. Follow your state’s statutory formalities to ensure enforceability.

How do I update or revoke my directive?

You can revoke or replace a directive by creating a new signed document or a written revocation delivered to your provider and agent. Immediately provide the updated form to your medical record department.

Where should I file the signed directive?

Provide copies to your named agent, primary care provider, and the medical records office at your Kaiser facility so the document is uploaded into the electronic health record.

What if my agent and family disagree?

Disputes may require legal resolution. Clear written instructions reduce conflict; if conflicts persist, facility ethics consultants or legal counsel may be involved to interpret the directive.

Electronic Signature
Templates
Legal
Kaiser Health Care Directives Form

Kaiser Health Care Directives Form

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

What the Kaiser Health Care Directives Form Is

The Kaiser Health Care Directives Form documents a patient's instructions about medical treatment choices and appoints a health care agent for decision-making if the patient becomes incapacitated. It typically includes a living will section for specific treatment preferences and a durable power of attorney for health care naming an agent. The form is used to ensure clinicians and medical records reflect the patient’s wishes across care settings within the Kaiser Permanente system and can be added to the electronic health record for reference by treating providers.

Why the Form Matters for Patient Care

Completing a Kaiser Health Care Directives Form ensures your treatment preferences are known and an authorized decision-maker is identified, reducing uncertainty during serious illness.

Who Typically Completes This Form

Patients, caregivers, and clinicians use the form to record preferences and name a health care agent before a crisis.

Patients with chronic or serious illnesses who want to document future treatment preferences.
Adults who wish to designate a surrogate decision-maker for health care choices.
Caregivers and family members coordinating care transitions or hospital admissions.

Step-by-Step: Completing the Kaiser Health Care Directives Form

Follow these ordered steps to complete the form and ensure it becomes part of the medical record.

01

Gather IDs: Have government ID and patient info ready.
02

Name Agent: Enter primary and alternate agent contact details.
03

State Preferences: Specify desired treatments and limits clearly.
04

Sign and Witness: Sign, date, and obtain witnesses or notarization as required.

Core Sections of a Complete Directive

A professional Kaiser Health Care Directives Form includes distinct sections to capture identity, decision authority, and treatment preferences clearly and legally.

Patient Identification

Full name, DOB, medical record number, and contact information to ensure the document is matched correctly in the electronic health record.

Health Care Agent

Designation of a primary surrogate with full contact details and authority scope, plus alternates to avoid gaps in decision-making.

Living Will

Clear statements about life-sustaining treatment, resuscitation, tube feeding, and other interventions to guide clinicians.

Limitations and Conditions

Optional detailed scenarios or conditions under which specific treatments should or should not be used, improving clarity for providers.

Witness / Notary

A witness and/or notary section to meet state formalities; some states require two witnesses or notarization for enforceability.

Provider Acknowledgment

Space for healthcare provider or facility staff to record receipt and inclusion in the medical record for continuity of care.

Required Data Elements at a Glance

Patient Name: Exact legal name

Date of Birth: MM/DD/YYYY

Agent Contact: Phone and address

Treatment Choices: Clear directives

Signatures: Patient and witnesses

Date Signed: MM/DD/YYYY

Supporting Documents to Include

Attach or provide related records to reduce ambiguity and speed processing when adding the directive to a medical file.

Photo ID

A copy of government-issued identification helps verify the patient’s identity when matching forms to the health record.

Previous Directives

Include any older advance directives or revocation documents so staff can reconcile and record the most recent instruction.

Physician Notes

Relevant clinical notes or diagnoses can clarify the context for the stated treatment preferences.

Power of Attorney

If a separate durable power of attorney for finances exists, include it to document roles across legal matters.

How to Complete and Submit Digitally

Configure the digital workflow to collect signatures, verify identity, and deliver the signed directive into the Kaiser medical record.

Field	Configuration
Signature Field	Require signature and date
Witness Fields	Conditional display per state rules
Authentication	Email plus optional SMS code
Delivery	Export PDF to EHR upload

Digital Signing and Submission Considerations

Ensure the signing platform supports secure authentication and preserves an audit trail for legal validity.

Document Formats: PDF and DOCX supported
Authentication: Email, SMS, or KBA
Recordkeeping: Audit trail and tamper-evident seal

Verify the platform meets HIPAA, ESIGN/UETA requirements and that the signed copy is stored with the patient’s medical record.

Distribution: How the Signed Form Moves Between Parties

Typical distribution routes ensure the directive is available to clinicians, agents, and the medical record after signing.

Patient to Agent: Provide signed copy to your health care agent immediately.
Upload to EHR: Clinic staff or patient uploads the PDF to electronic health record.
Clinic Reception: Front desk files copy in patient chart for admissions.
Emergency Access: Stored directive accessible to treating providers during urgent care.

Timing: When to Complete and Share the Form

Complete or update the directive whenever health status, preferences, or agents change; share it before admissions or major procedures.

Before Admission:

Provide the form to the admitting facility at or before hospital admission.

Post-Diagnosis:

Complete within weeks of a new serious diagnosis to document preferences.

After Major Change:

Update the form immediately after significant changes in health or relationships.

Periodic Review:

Review annually or when medications or prognosis change.

Upon Revocation:

Deliver revocation notice to provider and agent immediately.

Common Mistakes to Avoid

Using vague language that leaves treatment decisions open to interpretation by clinicians or courts.
Failing to name an alternate agent, creating a gap if the primary agent is unavailable or incapacitated.
Neglecting to follow your state’s witness or notarization requirements, which can invalidate the document.
Not providing signed copies to providers and the named agent, limiting the form’s practical effect.

Potential Consequences of an Incorrect or Incomplete Directive

Invalidation Risk: Mismatched signatures may make the directive unenforceable

Treatment Delay: Unclear instructions can delay clinically appropriate care

Legal Challenge: Family disputes may lead to court intervention

HIPAA Breach: Improper sharing risks violations

Administrative Rejection: Missing witness/notary can cause refusal

Outdated Instructions: Older versions may not reflect current wishes

eSignature Pricing Snapshot for Health Care Directives

Compare typical entry-level pricing and core features useful for healthcare directives; signNow is listed first per vendor comparison guidance.

	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	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 the Kaiser Health Care Directives Form

Answers below address common execution, legal validity, and submission issues when completing a directive for Kaiser care.

Need help? Contact support

Can I sign this form electronically?
Yes, electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA in most states, provided the platform demonstrates intent, consent, attribution, and record retention. Confirm devices and authentication meet any state-specific witness or notary requirements.
Is the form HIPAA-compliant when sent digitally?
Digital transfer must preserve privacy under HIPAA. Use a HIPAA-compliant platform and Business Associate Agreement if a third party handles protected health information; otherwise, avoid unsecured email for patient directives.
Do I need witnesses or a notary?
Witness and notary requirements vary by state. Some states require two witnesses or notarization for advance directives; others do not. Follow your state’s statutory formalities to ensure enforceability.
How do I update or revoke my directive?
You can revoke or replace a directive by creating a new signed document or a written revocation delivered to your provider and agent. Immediately provide the updated form to your medical record department.
Where should I file the signed directive?
Provide copies to your named agent, primary care provider, and the medical records office at your Kaiser facility so the document is uploaded into the electronic health record.
What if my agent and family disagree?
Disputes may require legal resolution. Clear written instructions reduce conflict; if conflicts persist, facility ethics consultants or legal counsel may be involved to interpret the directive.

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