Healthcare Directive
Document your healthcare wishes and designate a trusted person to make medical decisions on your behalf if you're unable to communicate them yourself.
This document combines your Healthcare Power of Attorney, Living Will, HIPAA Authorization, and organ donation preferences into one comprehensive directive.
Important: Healthcare directives must comply with your state's specific laws. We strongly recommend having this document reviewed by a qualified attorney. Find a Legal Professional
Reviewing a sample Healthcare Directive with example data highlighted in yellow.
ADVANCE HEALTHCARE DIRECTIVE
Healthcare Power of Attorney • Living Will • HIPAA Authorization
PART 1 — HEALTHCARE POWER OF ATTORNEY
I, Robert James Thompson, born on March 15, 1952, hereby designate the following person as my Healthcare Agent to make medical decisions on my behalf when I am unable to do so:
Primary Healthcare Agent:
Name: Susan Thompson-Clark
Relationship: Daughter
Phone: (602) 555-8901 | Email: susan.clark@email.com
Address: 5678 Maple Avenue, Mesa, AZ 85201
Alternate Healthcare Agent:
Name: David Michael Thompson
Relationship: Son
Phone: (602) 555-1234 | Email: david.thompson@email.com
My Healthcare Agent is authorized to: consent to or refuse medical treatment, select healthcare providers, approve or disapprove diagnostic tests and surgical procedures, and direct the provision, withholding, or withdrawal of life-sustaining treatment in accordance with my wishes stated below.
PART 2 — LIVING WILL / TREATMENT PREFERENCES
If I am in any of the following conditions, I direct my healthcare providers and agent to follow these wishes:
A. Terminal Condition
If I have an incurable condition that will result in death in a relatively short time:
✓ I do NOT want life-sustaining treatment. I want comfort care only.
B. Permanent Unconsciousness
If I am permanently unconscious with no reasonable expectation of regaining consciousness:
✓ I do NOT want life-sustaining treatment. I want comfort care only.
C. Specific Treatment Preferences
- ✓ CPR (Cardiopulmonary Resuscitation): Do NOT attempt
- ✓ Mechanical Ventilation: Do NOT use
- ✓ Tube Feeding / IV Nutrition: Do NOT use if permanently unconscious
- ✓ Pain Management: Provide maximum comfort care, even if it may hasten death
- ✓ Dialysis: Do NOT initiate
- ✓ Antibiotics: Use only for comfort
D. Additional Wishes
I want to die at home if possible. I want my family to be present. I want pastoral/spiritual care from my church. Please play my favorite hymns.
PART 3 — HIPAA AUTHORIZATION
I authorize my Healthcare Agent and Alternate Agent named above to access my protected health information under the Health Insurance Portability and Accountability Act (HIPAA), including medical records, test results, diagnoses, and treatment plans. This authorization shall remain in effect until revoked in writing.
Additional persons authorized to receive my health information:
- - James Thompson (Son) - (602) 555-5678
- - Dr. Sarah Mitchell (Primary Care Physician) - (602) 555-2222
PART 4 — ORGAN & TISSUE DONATION
Upon my death, I DO wish to donate my organs and tissues for:
- ✓ Transplantation
- ✓ Medical research
- ✓ Education
PART 5 — GENERAL PROVISIONS
This directive shall be governed by the laws of the State of Arizona. I understand that I may revoke this directive at any time by a signed writing, by physically destroying it, or by oral expression of my intent to revoke. I understand that this directive will be honored by my healthcare providers and agent as the final expression of my legal right to accept or refuse medical treatment.
SIGNATURES
Principal:
Robert James Thompson
Date
Healthcare Agent Acceptance:
Susan Thompson-Clark
Date
Witnesses:
Witness 1 Signature
Name: Michael R. Anderson
Address: 321 Pine St, Phoenix, AZ
Witness 2 Signature
Name: Patricia L. Nguyen
Address: 654 Elm Ave, Phoenix, AZ
Notary Acknowledgment
State of Arizona, County of Maricopa
On this _____ day of _______________, 20____, before me personally appeared
Robert James Thompson, known to me to be the person who executed the above document,
and acknowledged it as their free and voluntary act.
Notary Public
My commission expires: _______________
Subscribe to Create Your Own Healthcare Directive
Your subscription gives you full access to fill out, customize, and print your Healthcare Directive — with data auto-populated from your checklists.
With a subscription you get:
- Fillable Will, Power of Attorney, Healthcare Directive & Financial Snapshot
- Auto-populated templates from your checklist data
- Print-ready documents for signing
- Access to professional advisor directory
ADVANCE HEALTHCARE DIRECTIVE
Healthcare Power of Attorney • Living Will • HIPAA Authorization
PART 1 — HEALTHCARE POWER OF ATTORNEY
I, , born on , hereby designate the following person as my Healthcare Agent:
Primary Healthcare Agent:
Alternate Healthcare Agent:
My Healthcare Agent is authorized to: consent to or refuse medical treatment, select healthcare providers, approve or disapprove diagnostic tests and surgical procedures, and direct the provision, withholding, or withdrawal of life-sustaining treatment in accordance with my wishes stated below.
PART 2 — LIVING WILL / TREATMENT PREFERENCES
If I am in any of the following conditions, I direct my healthcare providers and agent to follow these wishes:
A. Terminal Condition
If I have an incurable condition that will result in death in a relatively short time:
B. Permanent Unconsciousness
If I am permanently unconscious with no reasonable expectation of recovery:
C. Specific Treatment Preferences
D. Additional Wishes
PART 3 — HIPAA AUTHORIZATION
I authorize my Healthcare Agent and Alternate Agent named above to access my protected health information under HIPAA, including medical records, test results, diagnoses, and treatment plans.
Additional persons authorized to receive my health information:
PART 4 — ORGAN & TISSUE DONATION
Upon my death, regarding organ and tissue donation:
Purpose of donation (check all that apply):
PART 5 — GENERAL PROVISIONS
This directive shall be governed by the laws of the State of . I understand that I may revoke this directive at any time by a signed writing, by physically destroying it, or by oral expression of my intent to revoke.
SIGNATURES
Principal:
Date
Healthcare Agent Acceptance:
Date
Witnesses:
Witness 1 Signature
Witness 2 Signature
Notary Acknowledgment
State of ,
County of
On this _____ day of _______________, 20____, before me personally appeared
the Principal named above, known to me to be the person who executed the above document,
and acknowledged it as their free and voluntary act.
Notary Public
My commission expires: _______________
Need Help With Your Healthcare Directive?
Your healthcare wishes deserve proper legal documentation. Our network of trusted legal professionals can ensure your directive meets your state's requirements and fully reflects your preferences.