Utah Advance Health Care Directive Form 2 - Free Download
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Utah Advance Health Care Directive Form 2
Utah Advance Health Care Directive Form 2
Part I: Allows you to name another person to make health care decisions for you when you
cannot make decisions or speak for yourself.
Part II: Allows you to record your wishes about health care in writing.
Part III: Tells you how to revoke or change this directive.
Part IV: Makes your directive legal.
C. My Alternate Agent
This person will serve as your agent if your agent, named above, is unable or unwilling to serve.
Alternate Agent’s Name: _______________________________________________________________
Street Address: _______________________________________________________________________
City, State, Zip Code: _________________________________________________________________
Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________
Work Phone: (_______) _____________________
Part I: My Agent (Health Care Power of Attorney)
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My Personal Information
Utah Advance Health Care Directive
(
Pursuant to Utah Code Section 75-2a-117
,
e
ff
ective 2009
)
*
Name: ______________________________________________________________________________
Street Address: _______________________________________________________________________
City, State, Zip Code: _________________________________________________________________
Telephone: (_______) _____________________ Cell Phone: (_______) _____________________
Birth Date: ____________________________
B. My Agent
Agent’s Name: _______________________________________________________________________
Street Address: _______________________________________________________________________
City, State, Zip Code: _________________________________________________________________
Home Phone: (_______) _____________________ Cell Phone: (_______) _____________________
Work Phone: (_______) _____________________
A. No Agent
If you do not want to name an agent, initial the box below, then go to Part II; do not name an agent in B
or C below. No one can force you to name an agent.
I do not want to choose an agent.
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