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How To Fill Out Forms

How to Fill Out the Health Care Proxy Form

  1. Write your name and the name, home address and telephone number of the person you are selecting as your agent.
  2. You may write the name, home address and telephone number of an alternate agent.
  3. If you have special instructions for your agent, you should write them here. Also if you wish to limit your agent's authority in any way, you should say so here. If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decision to consent to or refuse life sustaining treatment.
  4. This form will remain valid indefinitely unless you set an expiration date or condition for its expiration. This section is optional and should be filled in only if you want the health care proxy to expire.
  5. You must date and sign the proxy. If you are unable to sign yourself, you may direct someone else to sign in your presence. Be sure to include your address.
  6. Two witnesses at least 18 years of age must sign and date your proxy. The person who is appointed agent or alternate agent cannot sign as a witness.
     

How to Fill Out the Advance Care Directive (Living Will) Form

  1. Print your name, birth date, address and social security number.
  2. Print your full (legal) name in the space provided.
  3. Place a checkmark in the boxes for all the statements you agree with.
  4. Write any additional instructions you would like followed in the event you are not able to make decisions.
  5. You must date and sign the form. 
  6. Two witnesses at least 18 years of age must sign and date your Living Will. Your health care provider cannot sign as a witness.