When you receive this form事前医療指示書の要件は州によって異なります。あなたの州の政府ウェブサイトから州に合ったフォームを入手してください。州の保健局リンクは/usa/directory/の州ディレクトリを参照してください。病院は入院時にフォームを提供することがあります。入院まで待つ必要はありません。意思決定能力がある限り、いつでも事前医療指示書を作成できます。
What to bring or have ready事前医療指示書を作成するには、通常、あなたの医療代理人でも医療提供者でも遺産の受益者でもない成人の証人が2名必要です。公証を必要とする州もあります。署名前にあなたの州の要件を確認してください。
本人情報 / Principal Information
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Principal Name
本人氏名
The legal name of the person making this advance directive — the individual whose healthcare wishes are being recorded.
この事前医療指示書を作成する人の法的な氏名 — 医療に関する希望が記録される個人。
Date of Birth
生年月日
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.
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.
Contact information for your health care agent so that medical providers can reach them quickly in an emergency.
緊急時に医療提供者があなたの医療代理人に迅速に連絡できるよう、連絡先情報を記入してください。
Alternate Agent Name
代替エージェントの氏名
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.
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.
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.
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.
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.