Patient Details
Full legal name, date of birth, address, and identifier information so providers can match the directive to medical records without ambiguity and avoid mismatched identity problems.
A clear, compliant Medical Treatment Directive reduces ambiguity about patient intent, speeds provider acceptance, and documents authority for surrogate decision-making. It centralizes critical choices—life-sustaining treatment, CPR, ventilator use—and clarifies agent powers so clinicians and families can act consistently with the patient’s wishes.
This template is used by patients and by professionals who assist with advance care planning, including clinicians, attorneys, and care coordinators.
Use the template as a starting point; verify state witness or notarization rules and consider attorney review for complex cases.
The person whose medical preferences and agent designation are recorded. Must have capacity when signing; signature must match identity documentation when required by law or facility policy.
An appointed decision-maker authorized to accept or refuse treatments on the principal’s behalf when incapacity occurs; should carry a copy of the directive and contact clinicians promptly.
Full legal name, date of birth, address, and identifier information so providers can match the directive to medical records without ambiguity and avoid mismatched identity problems.
Specific treatment preferences (life‑sustaining care, CPR, feeding tubes, antibiotics, palliative comfort measures) written in plain language to guide clinicians accurately.
Name, relationship, contact information, and alternate agents so decision authority is clear if the primary agent is unavailable or unwilling to act.
Patient signature line with date plus spaces for witnesses or notary acknowledgement according to state requirements to ensure acceptance by hospitals and legal weight.
Optional release allowing clinicians to discuss care with the agent; limited, specific language prevents overbroad disclosures and supports continuity of care.
Instructions for how to revoke or revise the directive, and recommended periodic review dates so document remains current and representative of patient wishes.
| Field | Configuration |
|---|---|
| Patient Name | Auto-detected; required; read-only after sign |
| Agent Fields | Required contact; conditional alternate agent shown if primary missing |
| Witness Blocks | Optional or required per state selection; signature + printed name |
| Document Routing | Email copies to agent and designated provider upon completion |
Use an e-signature platform that supports form fields, conditional logic, and secure distribution to providers and agents.
Verify platform HIPAA support and business associate agreement availability before transmitting protected health information electronically.
Enter when the document is signed; it governs effectiveness and retention triggers.
Notify the agent immediately after signing so they can accept or prepare.
Provide a copy to the primary care provider on or before the next visit.
Review every 2–5 years or after major health events to confirm ongoing accuracy.
Document revocations in writing and distribute to the same parties who received the original.
Ensure all fields are filled before bringing witnesses or notary.
Principal signs in presence of required witnesses or a notary public.
Witnesses print names, addresses, and sign to confirm witnessing.
If chosen or required, notary completes acknowledgement and seals document.
Present notarized or witnessed copy to health care providers.
If e-signed, confirm state allows electronic acceptance for directives.
Upload to EHR and store a certified copy with agent.
Keep original signed document in a safe, accessible place.
| 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 | No | No | Yes, limited | Yes, limited |
| Bulk Send | Yes | Yes | Yes | Yes | No |
| Audit Trail | Yes | Yes | Yes | Yes | Yes |
| HIPAA Compliant | Yes | Yes | Yes | No | No |