Blank Utah Advance Health Care Form

The Utah Advance Health Care Directive is a legal document that allows individuals to appoint someone to make health care decisions on their behalf if they are unable to do so. This form also provides a space for individuals to outline their health care wishes in writing. Understanding this directive is essential for ensuring that your preferences are respected during critical moments.

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The Utah Advance Health Care Directive is a crucial legal document that empowers individuals to make important decisions about their health care in advance, ensuring their wishes are respected when they can no longer communicate them. This directive consists of several parts, each addressing different aspects of health care decision-making. Part I allows individuals to appoint an agent, a trusted person who can make health care decisions on their behalf if they become incapacitated. This section also outlines the agent's authority, which can include consenting to or refusing medical treatments, hiring health care providers, and accessing medical records. Part II offers a space for individuals to articulate their specific health care wishes, including preferences for life-sustaining treatments and comfort care. It presents various options, from allowing the agent to decide to explicitly refusing certain interventions. In Part III, individuals learn how to revoke or amend their directive, ensuring they maintain control over their health care decisions. Finally, Part IV formalizes the directive, affirming the individual's competency and voluntary consent. Understanding the nuances of this form is essential for anyone looking to secure their health care preferences in Utah.

File Information

Fact Name	Fact Details
Governing Law	The Utah Advance Health Care Directive is governed by Utah Code Section 75-2a-117.
Agent Appointment	Part I allows you to appoint an agent to make health care decisions on your behalf if you cannot do so.
Health Care Wishes	Part II enables you to document your specific health care wishes, including end-of-life decisions.
Revocation Process	Part III outlines how you can revoke or change your directive, including writing "void" across the form.
Legal Validity	Part IV ensures that your directive is legally binding when signed voluntarily by you.
Agent's Authority	Your agent can make various health care decisions, including consent to or refusal of treatment, as specified in Part I.
Limits on Authority	You can set limits on your agent's authority in Part I, ensuring your preferences are respected.
Guardian Nomination	Part I also allows you to nominate your agent as a guardian if necessary, which can help avoid guardianship proceedings.

Documents used along the form

The Utah Advance Health Care Directive is a crucial document for individuals wishing to outline their health care preferences and designate an agent to make decisions on their behalf. Alongside this directive, several other forms and documents may be relevant to ensure comprehensive planning for health care and end-of-life decisions. Below is a list of these documents, each serving a specific purpose.

Durable Power of Attorney for Health Care: This document allows you to appoint someone to make health care decisions for you if you become incapacitated. It is similar to the agent designation in the Advance Health Care Directive but may be used independently.
Living Will: A living will specifies your wishes regarding medical treatment in situations where you are unable to communicate. It focuses primarily on end-of-life care and the types of medical interventions you do or do not want.
Do Not Resuscitate (DNR) Order: A DNR order instructs medical personnel not to perform CPR if your heart stops or you stop breathing. This document is often used in conjunction with other advance directives to clarify your wishes regarding life-saving measures.
Non-disclosure Agreement: To protect sensitive information exchanged between parties, a Missouri Non-disclosure Agreement (NDA) is essential. To learn more about this important document, visit Missouri PDF Forms.
Organ Donation Consent Form: This form allows you to express your wishes regarding organ donation after your death. It ensures that your intentions are known and can be honored by your family and medical professionals.
HIPAA Authorization Form: This document gives permission for designated individuals to access your medical records and health information. It is important for ensuring that your agent or family members can make informed decisions about your care.
Physician Orders for Life-Sustaining Treatment (POLST): A POLST form translates your preferences regarding medical treatment into actionable medical orders. It is especially useful for individuals with serious illnesses who wish to ensure their wishes are followed in emergencies.
Guardian Nomination Form: This form allows you to nominate a guardian for yourself in case you become incapacitated. It is an important step in ensuring that someone you trust will make decisions on your behalf.
Advance Directive Registry: While not a document itself, registering your advance directive with a state registry can make it easier for healthcare providers to access your wishes in an emergency situation.
Health Care Proxy Form: This form designates a health care proxy to make decisions on your behalf if you are unable to do so. It is similar to the durable power of attorney but may have different legal implications in some states.

Utilizing these forms and documents in conjunction with the Utah Advance Health Care Directive can provide clarity and peace of mind regarding health care decisions. Each document serves a unique role in ensuring that your preferences are respected and followed, allowing you and your loved ones to navigate complex medical situations with confidence.

Common mistakes

Filling out the Utah Advance Health Care Directive form can be a critical process for ensuring that your health care wishes are honored. However, several common mistakes can undermine the effectiveness of this important document. One frequent error is failing to clearly identify an agent. Many individuals either neglect to name an agent or do not discuss their health care wishes with the person they choose. This can lead to confusion and potentially result in decisions being made that do not align with the individual's desires.

Another mistake involves not specifying the authority granted to the agent. The form allows for the agent to have extensive powers, but if these are not clearly defined or limited, it may lead to misunderstandings. For example, if someone does not initial the appropriate boxes regarding medical records or admission to facilities, their agent may not have the necessary authority to act in critical situations.

Additionally, many people overlook the importance of the health care wishes section. This part of the form allows individuals to express their preferences regarding life-sustaining treatments. Failing to choose an option or initialing more than one can render the directive ineffective. It is crucial to select only one option and ensure that it accurately reflects your wishes.

Moreover, individuals often forget to include an alternate agent. If the primary agent is unavailable or unwilling to act, having an alternate ensures that someone is prepared to make decisions on your behalf. Without this, there may be delays or complications in obtaining necessary care.

Another common oversight is neglecting to sign and date the form properly. The signature is essential for the directive to be legally binding. If the document is not signed or lacks a date, it may be considered invalid, which can lead to disputes and challenges when the directive is needed.

Lastly, many individuals fail to discuss their advance health care directive with family members or loved ones. Open communication can help ensure that everyone understands the individual's wishes and can support the agent in carrying them out. This conversation can prevent potential conflicts and confusion during difficult times.

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UTAH ADVANCE HEALTH CARE DIRECTIVE

(Pursuant to Utah Code Section 75-2a-117)

Part I: Allows you to name another person to make health care decisions for you when you cannot make decisions or speak for yourself.

Part II: Allows you to record your wishes about health care in writing.

Part III: Tells you how to revoke the form.

Part IV: Makes your directive legal.

MY PERSONAL INFORMATION

Name:

Street Address:

City, State, Zip Code:

Telephone:

Cell Phone:

Birth date:

PART I: MY AGENT (HEALTH CARE POWER OF ATTORNEY)

A.No Agent

If you do not want to name an agent: initial the box below, then go to Part II; do not name an agent in B or C below. No one can force you to name an agent.

_______

I do not want to choose an agent.

(Initial)

B.My Agent

Agent's Name:

Street Address:

City, State, Zip Code:

Home phone:

Cell Phone:

Work phone:

C.Alternate Agent.

This person will serve as your agent if your agent, named above, is unable or unwilling to serve.

Alternate Agent's Name:

Street Address:

City, State, Zip Code:

Home phone:

Cell Phone:

Work phone:

D.Agent's Authority

If I cannot make decisions or speak for myself (in other words, after my physician or

APRN finds that I lack health care decision making capacity under Section 75-2a-104 of the Advance Health Care Directive Act), my agent has the power to make any health care decision I could have made such as, but not limited to:

•Consent to, refuse, or withdraw any health care. This may include care to prolong my life such as food and fluids by tube, use of antibiotics, CPR (cardiopulmonary resuscitation), and dialysis, and mental health care, such as convulsive therapy and psychoactive medications.

This authority is subject to any limits in paragraph F of Part I or in Part II of this directive.

•Hire and fire health care providers.

•Ask questions and get answers from health care providers.

•Consent to admission or transfer to a health care provider or health care facility, including a mental health facility, subject to any limits in paragraphs E and F of Part I.

•Get copies of my medical records.

•Ask for consultations or second opinions.

My agent cannot force health care against my will, even if a physician has found that I lack health care decision making capacity.

E.Other Authority

My agent has the powers below ONLY IF I initial the "yes" option that precedes the statement. I authorize my agent to:

YES _____ NO _____	Get copies of my medical records at any time, even when I
	can speak for myself.
YES _____ NO _____	Admit me to a licensed health care facility, such as a
	hospital, nursing home, assisted living, or other facility for
	long-term placement other than convalescent or
	recuperative care.

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F.Limits/Expansion of Authority

I wish to limit or expand the powers of my health care agent as follows:

___________________________________________________________________

G.Nomination of Guardian

Even though appointing an agent should help you avoid a guardianship, a guardianship may still be necessary. Initial the "YES" option if you want the court to appoint your agent or, if your agent is unable or unwilling to serve, your alternate agent, to serve as your guardian, if a guardianship is ever necessary.

YES _____ NO _____	I, being of sound mind and not acting under duress, fraud,
	or other undue influence, do hereby nominate my agent, or
	if my agent is unable or unwilling to serve, I hereby
	nominate my alternate agent, to serve as my guardian in the
	event that, after the date of this instrument, I become
	incapacitated.

H.Consent to Participate in Medical Research

	YES _____ NO _____	I authorize my agent to consent to my participation in
		medical research or clinical trials, even if I may not benefit
		from the results.
I.	Organ Donation
	YES _____ NO _____	If I have not otherwise agreed to organ donation, my agent
		may consent to the donation of my organs for the purpose
		of organ transplantation.

PART II: MY HEALTH CARE WISHES (LIVING WILL)

I want my health care providers to follow the instructions I give them when I am being treated even if my instructions conflict with these or other advance directives. My health care providers should always provide health care to keep me as comfortable and functional as possible.

Choose only one of the following options, numbered Option 1 through Option 4, by placing your initials before the numbered statement. Do not initial more than one option. If you do not wish to document end-of-life wishes, initial Option 4. You may choose to draw a line through the options that you are not choosing.

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Option 1

_______

(Initial)

I choose to let my agent decide. I have chosen my agent carefully. I have talked with my agent about my health care wishes. I trust my agent to make the health care decisions for me that I would make under the circumstances.

Additional Comments: ________________________________________________________

Option 2

_______

(Initial)

I choose to prolong life. Regardless of my condition or prognosis, I want my health care team to try to prolong my life as long as possible within the limits of generally accepted health care standards.

Other: _____________________________________________________________________

Option 3

_______

(Initial)

I choose not to receive care for the purpose of prolonging life, including food and fluids by tube, antibiotics, CPR, or dialysis being used to prolong my life. I always want comfort care and routine medical care that will keep me as comfortable and functional as possible, even if that care may prolong my life.

If you choose this option, you must also choose either (a) or (b), below.

_______	(a) I put no limit on the ability of my health care provider or
(Initial)	agent to withhold or withdraw life-sustaining care.

If you selected (a), above, do not choose any options under (b).

_______	(b) My health care provider should withhold or withdraw
(Initial)	life-sustaining care if at least one of the following initialed
	conditions is met:

_____	I have a progressive illness that will cause death.
(Initial)
_____	I am close to death and am unlikely to recover.
(Initial)
_____	I cannot communicate and it is unlikely that my
(Initial)	condition will improve.
_____	I do not recognize my friends or family and it is
(Initial) unlikely that my condition will improve.
_____	I am in a persistent vegetative state.
(Initial)

Other: _____________________________________________________________________

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Option 4

_______ I do not wish to express preferences about health care wishes in this

(Initial) directive.

If you do not want emergency medical service providers to provide CPR or other life sustaining measures, you must work with a physician or APRN to complete an order that reflects your wishes on a form approved by the Utah Department of Health.

PART III: REVOKING OR CHANGING A DIRECTIVE

I may revoke or change this directive by:

1.Writing "void" across the form, or burning, tearing, or otherwise destroying or defacing this document or directing another person to do the same on my behalf;

2.Signing a written revocation of the directive, or directing another person to sign a revocation on my behalf;

3.Stating that I wish to revoke the directive in the presence of a witness who is 18 years of age or older; will not be appointed as my agent in a substitute directive; will not become a default surrogate if the directive is revoked; and signs and dates a written document confirming my statement; or

4.Signing a new directive. (If you sign more than one Advance Health Care Directive, the most recent one applies.)

PART IV: MAKING MY DIRECTIVE LEGAL

I sign this directive voluntarily. I understand the choices I have made and declare that I am emotionally and mentally competent to make this directive. My signature on this form revokes any living will or power of attorney form, naming a health care agent, that I have completed in the past.

___________________	________________________________________________
Date	Print name: ________________________

___________________________________________________________________________

City, County, and State of Residence

I have witnessed the signing of this directive, I am 18 years of age or older, and I am not:

1.Related to the declarant by blood or marriage;

2.Entitled to any portion of the declarant's estate according to the laws of intestate succession of any state or jurisdiction or under any will or codicil of the declarant;

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3.A beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transfer or death deed that is held, owned, made, or established by, or on behalf of, the declarant;

4.Entitled to benefit financially upon the death of the declarant;

5.Entitled to a right to, or interest in, real or personal property upon the death of the declarant;

6.Directly financially responsible for the declarant's medical care;

7.A health care provider who is providing care to the declarant or an administrator at a health care facility in which the declarant is receiving care; or

8.The appointed agent or alternate agent.

_______________________________	_______________________________________
Signature of Witness	Printed Name of Witness
_________________________________	______________	_________	_________
Street Address	City	State	Zip Code

If the witness is signing to confirm an oral directive, describe below the circumstances under which the directive was made.

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Similar forms

Health Care Power of Attorney (POA): Similar to the Utah Advance Health Care Directive, a Health Care POA allows you to designate someone to make medical decisions on your behalf when you are unable to do so. This document also outlines the authority granted to your agent in health care matters.
Quitclaim Deed Form: To facilitate property transfers, refer to our complete Quitclaim Deed documentation guide for accurate and legal completion.
Living Will: Like the directive, a Living Will expresses your wishes regarding medical treatment in situations where you are unable to communicate. It specifically addresses end-of-life care and the types of medical interventions you would or would not want.
Durable Power of Attorney for Finances: While the Advance Health Care Directive focuses on health care decisions, a Durable Power of Attorney for Finances allows someone to manage your financial matters if you become incapacitated. Both documents empower an agent to act on your behalf.
Do Not Resuscitate (DNR) Order: This document works in conjunction with the Advance Health Care Directive by specifically instructing medical personnel not to perform CPR if your heart stops or if you stop breathing. It clarifies your wishes regarding life-sustaining treatment.
Physician Orders for Life-Sustaining Treatment (POLST): Similar to the Advance Health Care Directive, a POLST form translates your treatment preferences into actionable medical orders. It is intended for patients with serious illnesses and provides clear guidance to health care providers.
Advance Directive for Mental Health Treatment: This document allows you to specify your preferences for mental health treatment in case you become unable to make decisions. It complements the Advance Health Care Directive by addressing mental health care specifically.
Organ Donation Consent Form: While the Advance Health Care Directive includes organ donation preferences, a separate Organ Donation Consent Form provides explicit consent for organ donation. It ensures that your wishes are clearly documented and legally recognized.
Guardian Nomination Form: Similar to the nomination section in the Advance Health Care Directive, this form allows you to nominate a guardian for yourself in case you become incapacitated. It ensures that your preferences for guardianship are known.
Health Care Proxy Form: This document is similar to the Advance Health Care Directive in that it allows you to appoint someone to make health care decisions for you. It may be used interchangeably with the Advance Health Care Directive in some states.
End-of-Life Care Plan: This plan outlines your preferences for care at the end of life, similar to the wishes documented in the Advance Health Care Directive. It may include specific instructions about comfort care, pain management, and other treatment preferences.

Key takeaways

Understanding the Utah Advance Health Care form is essential for making informed decisions about health care preferences. Here are key takeaways to consider:

Purpose of the Form: This form allows individuals to appoint someone to make health care decisions on their behalf when they cannot.
Agent Designation: You can choose to name an agent to make decisions for you, or you can opt not to name anyone.
Health Care Wishes: The form enables you to specify your health care preferences in writing, ensuring your wishes are known.
Revocation Process: You can revoke or change your directive at any time by following specific procedures outlined in the form.
Legal Authority: The form must be signed to be legally binding, revoking any previous directives you may have made.
Agent’s Powers: Your appointed agent can make decisions regarding medical treatment, including the ability to consent to or refuse care.
Limitations: You can impose limits on your agent’s authority, specifying what decisions they can or cannot make.
Health Care Provider Interaction: Your agent has the right to communicate with health care providers and obtain medical records.
End-of-Life Decisions: The form allows you to express your wishes regarding life-sustaining treatment and comfort care.
Witness Requirement: When signing the form, a witness must be present to confirm your capacity to make the directive.

Completing this form thoughtfully ensures that your health care preferences are respected and followed when you are unable to communicate them yourself.

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