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Utah Advance Health Care Directive(Living Will) Form |
The Utah advance health care directive(living will) form is a legal document (“Advance Directive”) that would be used by a person (Principal) who who is ready to prepare advance documentation, while they are of sound mind, in the event they are met with any situation that may leave the Principal unable to communicate their wishes for health care under end of life circumstances.
Once completed, the Principal will have legally recorded instructions as to the steps to be taken by their medical providers when they are no longer able to verbally communicate this information on their own. As well, the document will allow the Principal to assign their selected Agent, who will make medical decisions on behalf of the Principal when they are no longer able. Once completed, the document will require the signature of at least one (1) witness, which can be a disinterested person or a notary. This document, as long as the Principal is mentally able, may be changed or revoked as they see it to be necessary.
Laws – Utah Code 75-2a-101 et seq.: Advance Health Care Directive Act
How to Write
Step 1 – Personal Information – Submit the following:
- Name
- Street address
- City, State, Zip Code
- Telephone Number
- Cell phone
- Birth Date in mm/dd/yyyy format
Step 2 – Appointment of Agent – If the Principal would prefer not to appoint an agent, initial the first box in this section – If the Principal would like to have a health care agent to assist in medical care decisions and to work with their physicians, complete box B:
- Agent’s name
- Street Address
- City, State, Zip Code
- Home Phone
- Cell Phone
- Work Phone
If the initial Agent is unable or unwilling to provide assistance to the Principal and the principal would like to appoint an alternate agent, in advance, provide the alternate’s information as follows:
- Alternate Agent’s name
- Street Address
- City, State, Zip Code
- Home Phone
- Cell Phone
- Work Phone
- AND
- The Principal must read all of “Agent’s Authority”
- Agent’s authority while the Principal can speak for themselves – Only complete this section if you are willing to allow your agent to have access to your medical record and Health Care financial records. If not, leave the section blank. If so, the principal should complete the information according to their wishes
- Section F is concerning limits and expansion of authority to the agent – If the principal is interested in extending or limiting powers, check “yes” if not, leave them blank
- Section G – Nomination of Guardian – If the principal would like to allow the courts to appoint a guardian over their person, read the section and check “yes”
- Section H -If the Principal would like to offer consent to participate in Medical Research, authorize your agent to consent to participation
- Section J – If the principal would like to offer their organs for transplantation only check “yes” in this section. If not, leave this section blank
Step 3 – Health Care Wishes – The Principal must take the time to read each Option carefully –
- Select only one option and initial the line before the statement
- Provide any additional comments (if any)
- If there will be additional instruction with regard to the principal’s health care wishes, enter then into the “Additional Instructions” section
Step 4 – Revoking or Changing a Directive –
- The Principal must read this section in the event the would like to make changes or create a revocation
Step 5 – Legalizing the Directive – (Signatures)
- Upon completion of the document, the Principal must carefully read the statement available. If the principal agrees:
- Date the signature in mm/dd/yyyy format
- Submit the Principal’s signature in agreement
- Submit City, County and State of Residence
Witness – This document will require the signature of one witness
- The witness must carefully review the criteria in which they may be eligible to witness on behalf of the principal – if in agreement:
- Enter the signature of the witness
- Enter the printed name of the witness
- Enter their Street address, City, State and Zip Code
- If the witness will sign to confirm an oral directive, provide a description in which the directive was made
- Enter the name of the witness
