Minnesota Advance Health Care Directive (Living Will) Form

The Minnesota advance health care directive(living will) form is a document that is generally utilized by an individual (Principal) who has considered the possibilities, for whatever reason, that they may one day approach a point in their life that they will no longer be able to communicate their own health care decisions. The Principal, by the guidance of this document, would be able to clearly record their carefully considered health care decisions for their health care providers, family and health care agent (who may be appointed within the confines of this document).

Once completed, this document must be witnessed in order to be legally effective. Should the Principal decide they would like to make changes or revoke the document, they are free to do so at their own discretion.

Laws – 145C.01 Health Care Directive

How to Write

Step 1 – Download the document – Enter the Principal’s name at the top of the form to establish the declarant –

  • The Principal must carefully read the remainder of this section and then enter their name again, above parts 1 and 2

Step 2 – Appointment of Health Care Agent – The Principal must read the first paragraph of this section prior to proceeding. If in agreement, submit the following:

  • Enter the name of the appointed agent
  • Relationship of the health care agent to the Principal
  • Telephone number
  • Agent’s complete address
  • AND

In the event the initial agent is (for whatever the reason) unavailable to serve, the Principal has the option of naming an alternate agent by providing their information:

  • The name of the alternate agent
  • Relationship of the health care agent to the Principal
  • Telephone number
  • Agent’s complete address

Step 3 – Principal’s Delegation of Powers – The Principal must read through these powers –

  • If the Principal would like to restrict or limit their agent’s powers, enter the restrictions or limits into the lines provided
  • If more room is required, add a continuation page and attach it to the document
  • If the Principal would like to expand the information they would like to provide regarding their health care wishes, enter that information into the second set of lines provided in this section

Step 4 – Health Care Instructions – The Principal must read the “Note” at the beginning of this section –

  • Read each statement and respond in the lines provided
  • Each is optional, the Principal may respond to some, all or none

Step 5 – Specific Preference Instructions – The Principal must review the paragraph at the beginning of the section –

  • Read each statement (1 through 5) with regard to what the Principal would like to include in the medical protocol and respond to the statements that apply
  • AND
  • In the second half of this section, the Principal must read each of the statements regarding what they may not wish to include in their medical protocol and respond

Step 6 – Signatures, Witnesses OR Notarization – These signatures will make the document legally effective. The Principal may use two unrelated witnesses or notarization

  • The Principal must enter their signature
  • Date signed in mm/dd/yyyy format
  • Date of Birth in mm/dd/yyyy format
  • Complete address
  • If someone had to sign the document on behalf of the Principal they must provide signature and their printed name
  • If the Principal selects a notary public as witness, they must not sign the document until they are present before the notary
  • The notary will witness the Principal’s signature and acknowledge it by completing the notary section of the document
  • OR
  • If two witnesses will be signing, they must provide their information in the presence of one another
  • Each must read the witness statements
  • Enter the date of signature by entering the day of the week and the actual date in mm/dd/yyyy format
  • Submit the witnesses signatures
  • Provide the witnesses complete addresses
  • The Principal must read the reminder and provide copies to all signatories and any other interested parties