ADVANCE HEALTHCARE DIRECTIVE

This Advance Healthcare Directive ("Directive") is made by __________ ("Declarant"), born __________, residing at __________, __________, __________ __________ , as of __________.

1. REVOCATION OF PRIOR DIRECTIVES

This Directive revokes any prior advance healthcare directive, living will, or healthcare power of attorney previously executed by the Declarant, to the extent of any conflict with the instructions set forth herein.

2. DESIGNATION OF HEALTHCARE AGENT

The Declarant appoints the following individual as healthcare agent, with authority to make healthcare decisions on the Declarant's behalf in the event the Declarant is unable to do so:

Primary Agent: __________ (__________), reachable at __________ / __________ .

If the Primary Agent is unavailable, unwilling, or unable to serve, the Declarant appoints the following Alternate Agent: __________ (__________), reachable at __________ / __________ .

3. EFFECTIVE DATE / DETERMINATION OF INCAPACITY

This Directive becomes effective when the Declarant's attending physician determines, in writing, and in accordance with applicable state law, that the Declarant lacks the capacity to make or communicate their own healthcare decisions. This Directive remains effective during the period of incapacity and ceases to apply if and when the Declarant regains such capacity.

4. STATEMENT OF TREATMENT PREFERENCES

4.1 Life-Sustaining Treatment: __________

4.2 Resuscitation: __________

4.3 Artificial Nutrition and Hydration: __________

4.4 Pain Management: __________

5. CONDITIONS UNDER WHICH THIS DIRECTIVE APPLIES

The instructions in Section 4 apply if the Declarant is diagnosed with: __________.

6. ORGAN AND TISSUE DONATION

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7. HIPAA AUTHORIZATION

The Declarant authorizes any physician, healthcare provider, hospital, or other medical institution to disclose the Declarant's protected health information under HIPAA (45 CFR Parts 160 and 164) to the healthcare agent(s) named in Section 2, for the purpose of making informed healthcare decisions on the Declarant's behalf.

8. GOOD FAITH RELIANCE

Any physician, healthcare provider, or institution that relies in good faith on the instructions in this Directive, or on the decisions of the healthcare agent named herein, shall not be subject to civil or criminal liability or professional disciplinary action as a result of that reliance.

9. GOVERNING LAW

This Directive shall be governed by and construed in accordance with the laws of the State of __________.

10. SEVERABILITY

If any provision of this Directive is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

11. WITNESS & NOTARIZATION REQUIREMENTS

Based on the Declarant's state of residence (__________), this Directive requires: 2 witness(es), and notarization is: confirm with state statute.

This state was not found in our reference table. Confirm the exact witness and notarization requirements against the current statute for this state before finalizing.

This section is generated based on the Declarant's stated state of residence and should be confirmed against the current statute for that state before the document is treated as final.

IN WITNESS WHEREOF, the Declarant has executed this Directive as of the date first written above.

Signed by: __________
Signed on: __________

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