Can I sign the directive electronically?

Yes. Electronic signatures are valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided the signature demonstrates intent, consent, attribution, and the record is retained in reproducible form.

What witness or notary steps are required?

Requirements vary by state and form version. Some jurisdictions accept two witnesses, others require notarization; check the Vermont Department of Health guidance or the form instructions to confirm the required attestation.

How do I revoke or update a directive?

You may revoke by executing a revocation form, signing a new directive that expressly supersedes the prior one, or by physically destroying the prior document; notify your agent and providers to avoid relying on the old copy.

Where should I store the completed directive?

Keep the original with your personal records, give copies to your agent and clinicians, and upload a secure electronic copy to patient portals or a secure eSignature platform with audit trail capabilities.

Does HIPAA affect sharing the directive?

Yes. When the directive contains protected health information, HIPAA governs disclosure and retention. Covered entities and business associates must safeguard PHI and follow 45 CFR §164.530(j) for record retention.

What if my named agent cannot act?

If the primary agent is unavailable, the alternate agent named in the directive typically steps in. If no alternate exists, Vermont law or the facility’s policies guide surrogate decision-making — consider naming alternates to avoid gaps.

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Vermont Advance Directive for Health Care

Vermont Advance Directive for Health Care

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

VERMONT ADVANCE DIRECTIVE FOR HEALTH CARE

Pursuant to 18 V.S.A. 9703

Name

Date of Birth

Address

Part One: Appointment of My Health Care Agent

I appoint

Address

Telephone Mobile phone E-mail

as my Health Care Agent to make any and all health care decisions for me, except to the extent that I state otherwise in this document.

If this health care agent is unavailable, unwilling or unable to do this for me, I appoint to be my Alternate Agent.

Address:

Telephone Mobile phone E-mail

Others who can be consulted about medical decisions on my behalf include:

Those who should NOT be consulted include:

INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH.

A. General Grant of Power and Authority. Subject to any limitations in this Directive, my agent has the power and authority to do all of the following: (1) Request, review and receive any information, verbal or written, regarding my physical or mental health including, but not limited to, medical and hospital records; (2) Execute on my behalf any releases or other documents that may be required in order to obtain this information; (3) Consent to the disclosure of this information; and (4) Consent to the donation of any of my organs for medical purposes.

B. HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164.

(Optional space below is to identify your doctor or health care provider:) *Your doctor cannot also serve as your health care agent.

Primary care physician

Address

Office Telephone:

Part Two: Treatment Wishes

Please express your preferences that follow by checking or initialing the statements. You may check or initial more than one choice.

A. My Choice is to Limit Treatment - I do not want to be kept alive if:

1. I am so sick that I will die within a relatively short time (I cannot get better and have only weeks, days or hours left to live).

2. I become unconscious or unaware of my surroundings and most doctors agree that I will never regain consciousness.

3. I become unable to think or act for myself (and won’t get better).

4. The likely risks and burdens of treatment would outweigh the expected benefits.

5. If it is possible that I might recover with treatment and more time is needed, I wish my medical team to start the necessary treatments to keep me alive; if these treatments do not improve my chances, I wish to have life-sustaining treatment stopped.

6. If I have initialed or checked any of the situations above and am unable to swallow enough food and water to stay alive, I do want food and water to be given to me by vein or by feeding tube.

7. If I have initialed or checked situations 1-5, I do not want food and water to be given to me by vein or feeding tube, but I will accept medication for pain and agitation through an intravenous line.

8. Other specific instructions are as follows:

B. My Choice is to Sustain Life - I want to be kept alive as long as possible through any means possible regardless of my condition or awareness.

C. Specific Care Wishes Near the End of My Life

If it becomes clear to my doctor, my agent and those caring for me that I am dying, I want palliative care for my pain, worries, nausea and other conditions that bother me.

I want hospice care when I am dying, if possible and appropriate.

I prefer to die at home, if this is possible.

D. Spiritual and Other Care Concerns:

I am of the faith.

Church, Synagogue or Worship Center:

Address: Leader phone #

Other people to notify if I have a life-threatening illness:

Part Three: Specific Instructions about ORGAN DONATION

I want my agent (if I have appointed one), family, friends and all who care about me to follow my wishes about organ donation if that is an option at the time of my death. (Initial below all that apply.)

I do not wish to be an organ donor.

I wish to donate the following organs and tissues:

any needed organs or tissues

major organs (heart, lungs, kidneys, etc.)

tissues such as skin and bones

eye tissue such as corneas

I desire to donate my body to research or educational programs.

It is very important that you talk with your family and your health care agent about your wishes regarding organ donation.

If an autopsy is suggested for any reason, I give my permission to have it done.

Part Four: Desires for Disposition of my Remains after Death

1. The person I want to serve as my agent for disposition of my body is

a. I want my health care agent to decide arrangements after my death.

If he or she is not available, I want my alternate agent to decide.

b. Regardless of my appointment of a health care agent above, I appoint the following person to decide about and arrange for the disposition of my body after my death.

Address:

Telephone:

c. I want my family to decide.

II. My preference for burial and disposition of my remains after death.

a. I want a funeral followed by burial in a casket at the following location, if possible:

b. I want to be cremated and have my ashes buried or distributed as follows:

c. I want to have arrangements made at the direction of my agent or family.

I have a pre-need contract for funeral arrangements with the following funeral service:

Part Five: Signed Declaration of Wishes

Signed

Date

The witnesses below affirm that the principal appeared to understand the nature of the document and to be free from duress or undue influence.

Your agent, spouse, reciprocal beneficiary, parent, adult sibling, adult child or adult grandchild may NOT be a witness. Appointed agents, family members, heirs, health care providers, funeral service staff and anyone to whom you owe money may not be witnesses.

Witness Signature

(Printed Name)

Address

Witness Signature

(Printed Name)

Address

If the maker is a current patient or resident in a hospital, nursing home or residential care home, the following additional witness confirms the maker’s capacity, understanding, and freedom from undue influence (Hospital Explainer or Long-term-care Ombudsman or clergy, attorney, probate court designee):

Name

Address

Title/position Date

What the Vermont Advance Directive for Health Care Is

The Vermont Advance Directive for Health Care is a legal document that lets an adult name a health care agent, record treatment preferences, and give instructions for end-of-life care in case they become unable to make decisions. The form can cover CPR, ventilation, tube feeding, comfort care, organ donation, and agent authority. Clinicians and facilities use a completed directive to guide care when a patient lacks capacity. When properly executed it can be stored electronically and, when compliant with ESIGN/UETA rules, accepted as legally enforceable evidence of intent.

Why a Clear Advance Directive Matters

A completed Vermont Advance Directive for Health Care documents your choices, appoints a trusted agent, and reduces uncertainty during crises. It helps clinicians align care with your values and limits family conflict by clarifying decisions in advance.

Who Typically Uses This Form

Typical users include adults planning future medical decisions, appointed health care agents, and clinicians who must interpret and implement treatment preferences.

Adults who want to document health-care choices and name a decision-maker in case of incapacity.
Designated health care agents or proxies tasked with communicating and enforcing the patient’s stated wishes.
Hospitals, physicians, and long-term care facilities that rely on directives during treatment and emergency decisions.

Keep copies with your primary care provider, your chosen agent, and in your personal records so the directive is available when needed.

Step-by-Step: Completing the Vermont Advance Directive for Health Care

Follow these sequential steps to complete and preserve a valid Vermont Advance Directive for Health Care.

01

Gather Information: Collect full names, DOB, contact details, and medical proxies.
02

Choose Agent: Name primary agent and include alternate agent details.
03

Specify Preferences: Write explicit treatment directives and conditional instructions.
04

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

Key Parts of a Professional Vermont Advance Directive for Health Care

Core elements of the Vermont Advance Directive for Health Care define authority, specific treatments, organ donation, effective dates, and required attestations for legal clarity.

Agent Appointment

Names the person authorized to make health decisions on your behalf, including contact info and any limitations. Clearly state scope to prevent ambiguity in emergency care.

Treatment Choices

Specifies preferences for life-sustaining treatments such as CPR, mechanical ventilation, dialysis, and artificial nutrition, including any conditions that modify those preferences.

End-of-Life Decisions

Indicates whether to pursue comfort-focused care or aggressive interventions when prognosis is terminal or recovery unlikely; can include do-not-resuscitate preferences.

Organ Donation

Optional section where you accept, limit, or refuse organ and tissue donation, specify timing, and provide any conditions or registries to notify.

Effective Date

Records when the directive becomes operative and whether it activates immediately or only upon incapacity; precision matters for clinical and legal interpretation.

Witness/Notary

Provides space for witness signatures or notary acknowledgement as required; method of attestation affects acceptance in some clinical and legal settings.

Security and Compliance Considerations

Encryption: TLS 1.2 and TLS 1.3 in transit.

Data at Rest: AES-256 encryption for stored documents.

Audit Trail: Comprehensive signing history and timestamps.

HIPAA: HIPAA-compliant workflows; BAA required.

Access Controls: Role-based permissions and SSO support.

Certifications: SOC 2 Type II and ISO 27001.

Common Pitfalls to Avoid

Leaving ambiguous treatment preferences that do not specify conditional triggers leads to confusion and inconsistent application by clinicians and agents.
Failing to name an alternate agent creates a gap if the primary agent is unavailable or unwilling to act during a crisis.
Using nicknames or initials instead of full legal names can cause identity mismatches with medical records and legal documents.
Not distributing signed copies to providers, hospitals, and the appointed agent reduces the chance the directive will be found when needed.

Risks if the Directive Is Incorrect or Incomplete

Invalidation: Unsigned or improperly witnessed documents.

Family Disputes: Conflicting instructions increase litigation risk.

Clinical Delay: Providers may delay care pending clarification.

HIPAA Exposure: Improper sharing of PHI risks penalties.

Agent Misuse: Agent exceeds authority or acts wrongly.

Revocation Confusion: Unclear revocation can cause enforcement issues.

How Electronic Completion and Submission Works

Electronic completion and transmission typically follow a simple upload, signature placement, authentication, and storage workflow compatible with ESIGN and UETA.

Upload: Upload PDF or DOCX of directive.
Place Fields: Add signature, date, and initial fields.
Authenticate: Verify signer via email or multi-factor.
Store: Store signed copy with audit trail.

Suggested Digital Workflow Settings

Configure a digital workflow to collect signatures, apply witness logic, and route completed directives to designated parties.

Field	Configuration
Signature Field	Required for patient; date auto-filled.
Witness Field	Optional; add when state requires witnesses.
Notary Block	Include when notarization is elected or required.
Delivery Settings	Email copies to agent, provider, and record.

Platform Capabilities to Check Before Using eSignature

Ensure the eSignature platform supports secure authentication, HIPAA safeguards, and PDF/A output for long-term storage.

Authentication: Email, SMS, or multi-factor options.
Audit Trail: IP, timestamp, and action log retained.
Integrations: Connectors for EHR, Google Drive, and Box.

Entry-Level Pricing and Core Capabilities — signNow and Competitors

Comparison of entry-level pricing and common capabilities to consider when selecting an eSignature platform for health-care directives.

	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	Yes
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently Asked Questions About the Vermont Advance Directive for Health Care

Answers to common questions about execution, electronic signatures, witness and notary requirements, revocation, and storage practices.

Need help? Contact support

Can I sign the directive electronically?
Yes. Electronic signatures are valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided the signature demonstrates intent, consent, attribution, and the record is retained in reproducible form.
What witness or notary steps are required?
Requirements vary by state and form version. Some jurisdictions accept two witnesses, others require notarization; check the Vermont Department of Health guidance or the form instructions to confirm the required attestation.
How do I revoke or update a directive?
You may revoke by executing a revocation form, signing a new directive that expressly supersedes the prior one, or by physically destroying the prior document; notify your agent and providers to avoid relying on the old copy.
Where should I store the completed directive?
Keep the original with your personal records, give copies to your agent and clinicians, and upload a secure electronic copy to patient portals or a secure eSignature platform with audit trail capabilities.
Does HIPAA affect sharing the directive?
Yes. When the directive contains protected health information, HIPAA governs disclosure and retention. Covered entities and business associates must safeguard PHI and follow 45 CFR §164.530(j) for record retention.
What if my named agent cannot act?
If the primary agent is unavailable, the alternate agent named in the directive typically steps in. If no alternate exists, Vermont law or the facility’s policies guide surrogate decision-making — consider naming alternates to avoid gaps.

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