Advance Directive / Healthcare Decision Form

This form allows residents to document basic healthcare decision preferences and identify trusted people who may speak on their behalf if needed. Please complete this form carefully. Healthy Hearts Home Living will keep this information on file as part of the resident’s records. If you are unsure how to complete this form, you may want to speak with a trusted family member, healthcare provider, or legal professional before submitting it.

Resident / Declarant Full Name

Date of Birth

Phone Number

Email Address

Current Address

City and State of Residence

Healthcare Treatment Preferences

Terminal Condition Treatment Preference

I request comfort care only and allow my physician to withhold or discontinue life-sustaining treatment.

I request to be kept alive using available life-sustaining treatment.

I prefer to discuss this with my healthcare provider or family.

Irreversible Condition Treatment Preference

I request comfort care only and allow my physician to withhold or discontinue life-sustaining treatment.

I request to be kept alive using available life-sustaining treatment.

I prefer to discuss this with my healthcare provider or family.

Additional Medical Requests or Instructions

Healthcare Spokesperson

Healthcare Spokesperson Name

Healthcare Spokesperson Relationship

Healthcare Spokesperson Phone Number

Healthcare Spokesperson Email Address

Alternate Healthcare Spokesperson Name

Alternate Healthcare Spokesperson Phone Number

Acknowledgement and Signature

Advance Directive Acknowledgement

I understand that this form documents my healthcare decision preferences and trusted healthcare contact information. I understand that I may update or revoke these preferences according to applicable laws and procedures.

Resident / Declarant Signature or Typed Name

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Signature Date

Witness Printed Name

Witness Signature or Typed Name

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Witness Signature Date