Note: This is a reference translation to help you understand a typical form. It is not an official document. Your provider's actual form may differ — always sign the provider's own version.
When you receive this formAdvance directive requirements vary by state. Obtain the form for your state from your state government website — see the state directory at /usa/directory/ for state health department links. A hospital may offer the form during admission. You do not have to wait for a hospitalization — you can complete an advance directive at any time while you have decision-making capacity.
What to bring or have readyTo complete an advance directive, you typically need two adult witnesses who are not your health care proxy, not your healthcare provider, and not a beneficiary of your estate. Some states also require notarization. Check your state's requirements before signing.
Principal Information
English
What this field means
Principal Name
The legal name of the person making this advance directive — the individual whose healthcare wishes are being recorded.
Date of Birth
The principal's date of birth, used to identify this individual in medical records and confirm they are an adult of legal age to execute this document.
Current Address
The principal's current home address. Some states use this to establish residency and confirm the correct state form is being used.
Healthcare Proxy / Agent Designation
English
What this field means
Health Care Proxy / Agent Name
The full legal name of the person you are naming to make healthcare decisions on your behalf if you become unable to do so. This person is often called a health care proxy, health care agent, or durable power of attorney for healthcare.
Agent Address and Phone Number
Contact information for your health care agent so that medical providers can reach them quickly in an emergency.
Alternate Agent Name
An alternate or successor agent who will act if your primary agent is unavailable, unwilling, or unable to serve. Naming an alternate helps ensure your wishes can be honored.
Alternate Agent Address and Phone Number
Contact information for your alternate health care agent so they can be reached if the primary agent cannot be contacted.
Treatment Preferences Summary
English
What this field means
General Treatment Preference Statement
A free-text space for you to describe your general wishes regarding medical treatment — for example, under what circumstances you would or would not want life-sustaining treatment, what matters most to you in your care, or other guidance for your agent and providers. Write in your own words. Your specific state form may structure this section differently.
Witness and Notarization Requirements
English
What this field means
Witness 1 — Name and Signature
An adult witness who signs to confirm they observed the principal signing this document voluntarily. State requirements vary, but witnesses generally may not be your health care agent, your healthcare provider, or a beneficiary of your estate.
Witness 2 — Name and Signature
A second adult witness, subject to the same requirements as Witness 1. Having two witnesses is standard across most states, though the specific eligibility rules differ. Check your state's advance directive requirements.
Notarization Required (varies by state)
Some states require a notary public to witness and stamp the document in addition to the two witnesses. Other states accept witnesses alone. This field indicates whether notarization applies — check your specific state's advance directive law to confirm.