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Utah Uniform Probate Code | |
Advance Health Care Directive Act | |
Section 117 | Optional form. |
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75-2a-117. Optional form. (1) The form created in Subsection (2), or a substantially similar form, is presumed valid under this chapter. (2) The following form is presumed valid under Subsection (1): 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 or change this directive. Part IV: Makes your directive legal. __________________________________________________________________________ Name: ____________________________________________________________________ Street Address: _____________________________________________________________ City, State, Zip Code: _____________________________________________________________ Telephone: _________________________ Cell Phone: ____________________________ Birth date: _____________ ____________________________________________________________________________ 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. B. My Agent Agent's Name: ______________________________________________________________ Street Address: ______________________________________________________________ City, State, Zip Code: ______________________________________________________________ Home Phone: ( ) _________ Cell Phone: ( ) _________ Work Phone: ( ) __________ C. My 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 another authorized provider 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: 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. _____________________________________________________________________ Additional instructions about your health care wishes: ______________________________________________________________________________ __________________________________________________________________________ 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. 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.) 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 ________________________________________________ Signature ____________________________________________________________________________ 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; 3. a beneficiary of a life insurance policy, trust, qualified plan, pay on death account, or transfer on 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. ______________________________________________________________________________ __________________________________________________________________________
Amended by Chapter 99, 2009 General Session |
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