Advance Healthcare Directive
An easy-to-use form to make your goals, values and preferences known
Why should you have an
Advance Healthcare Directive?
It is important to plan ahead and clearly state your healthcare goals, values and
preferences. An Advance Healthcare Directive is the best place to do this. Your
completed directive will give you and those close to you greater peace of mind.
The process of filling out your directive may also help you talk with loved ones
about what matters most to you.
There also is a number of resources available at Cedars-Sinai to help you complete
your directive, including social workers, spiritual care experts and a free Advance
Care Planning class. For information on these and other resources, please see the
back cover of this document.
What should you do after you
have completed your
Advance Healthcare Directive?
1. Have your directive notarized or signed by two eligible witnesses.
• Option 1: Sign the document in the presence of a notary public.
• Option 2: Have two eligible witnesses sign the document.
2. Share copies with:
• Your healthcare agent(s)
• Your loved ones
• Your main physician
• Your lawyer
3. Make sure it is uploaded into your electronic medical record, using one of the
following options:
Upload to
My CS-Link
Website:
mycslink.org
Use the Advance
Healthcare Directive
page listed
under Resources.
Please include your
name and date of birth
on the first page.
Fax Number:
310-248-8078
Please include your
name and date of birth
on the first page.
Mailing Address:
Health Information
Department
8700 Beverly Blvd.
South Tower, Room 2901
Los Angeles, CA
90048
Please include your
name and date of birth
on the first page.
Email Address:
groupMNSHID@cshs.org
Please include your
name and date of birth
on the first page.
Email an
electronic copy
to Cedars-Sinai
Mail to
Cedars-Sinai
Fax to
Cedars-Sinai
4. Keep the original copy in a safe (but accessible) place.
1
PART 1:
My Healthcare Agent
Section A: Choosing My Healthcare Agent 2
Section B: When Would I Like My Healthcare Agent 3
to Begin Representing Me?
PART 2:
My Healthcare Goals, Values and Preferences
Section A: Quality of Life 4
Section B: Scope of Tretment 5
Section C: Further Explanation (Optional) 6
PART 3 (OPTIONAL):
Additional Preferences:
Organ Donation
My Wishes for After I Die
7
PART 4:
How Strictly Do I Want My
Advance Healthcare Directive Followed?
8
PART 5 (OPTIONAL):
Identifying My Physician 9
PART 6:
Signing My Advance Healthcare Directive 11 – 15
Extra Pages
16–17
Additional Resources Back Cover
Table of Contents
2
My Name: ___________________________________________________________
My Date of Birth: ___________________________________________________
PART 1:
My Healthcare Agent
SECTION A CHOOSING MY HEALTHCARE AGENT
n For help with filling out this section, please refer to Part 1 Section A of the
Step-by-Step Guide (Pages 3-4).
I choose the following person to speak on my behalf if at any time I am not able
to (or choose not to) express my own goals, values and preferences:
Healthcare Agent’s Name: _______________________________________________
Relationship to You: _____________________________________________________
Phone Number(s): _______________________________________________________
Email Address (if known): ________________________________________________
The following person(s) can serve as alternate agents (this is optional):
First Alternate
Alternate Agent’s Name: _________________________________________________
Relationship to You: _____________________________________________________
Phone Number(s): _______________________________________________________
Email Address (if known): ________________________________________________
Second Alternate
Alternate Agent’s Name: _________________________________________________
Relationship to You: _____________________________________________________
Phone Number(s): _______________________________________________________
Email Address (if known): ________________________________________________
3
Part 1 (continued)
SECTION B
WHEN WOULD I LIKE MY HEALTHCARE AGENT
TO BEGIN REPRESENTING ME?
For help with filling out this section, please refer to Part 1 Section B of the
Step-by-Step Guide (Page 5).
I would like my healthcare agent to begin participating in decision-making
about my healthcare at the following time:
Please complete the sentence above by initialing either option 1 or option 2:
Option 1
When my physician determines that I am unable to express my own goals,
v
alues and preferences.
___________________
(Initial Here)
OR
Option 2
From this time forward, even if I am still able to speak for myself.
___________________
(Initial Here)
4
If you would like to share additional details, please use any of the lined spaces provided on
page 6 or at the end of this document.
PART 2:
My Healthcare Goals, Values and Preferences
SECTION A QUALITY OF LIFE
n For help with filling out this section, please refer to Part 2 Section A of the
Step-by-Step Guide (Pages 6-9).
My life would be worth living, and therefore I would want my life to be
prolonged as long as possible, under the following circumstances:
Please complete the sentence above by selecting option 1, 2 or 3:
Option 1

All circumstances—even if it means only the basic functioning of my organs
(heart, lungs, kidneys, etc.) with or without machines.
OR
Option 2

All circumstances, unless I would NEVER recover the ability to (please fill in
the space below):
Physical and Bodily Considerations (e.g., live without being permanently
connected to mechanical life support, get out of bed, go outside):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Cognitive Considerations (e.g., be awake, be conscious, be able to think clearly):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Interactive, Social and Community Considerations (e.g., communicate in
some way with other people, live outside of a healthcare facility):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
OR
Option 3

I am not sure.
5
If you would like to share additional details, please use any of the lined spaces provided on
page 6 or at the end of this document.
Part 2 (continued)
SECTION B SCOPE OF TREATMENT
n For help with filling out this section, please refer to Part 2 Section B of the
Step-by-Step Guide (Pages 10-11).
If my physician believes that I have a reasonable chance of recovering to the
quality of life I stated on page 4, I would be willing to undergo the following:
Please complete the sentence above by selecting option 1, 2 or 3:
Option 1

All procedures, treatments and interventions oered by my healthcare team.
OR
Option 2

All procedures, treatments and interventions oered by my healthcare team, EXCEPT:
___________________________________________________________________________________
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___________________________________________________________________________________
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___________________________________________________________________________________
___________________________________________________________________________________
OR
Option 3

I am not sure.
6
If you would like to share additional details, please use any of the lined spaces provided at the
end of this document.
Part 2 (continued)
SECTION C FURTHER EXPLANATION (OPTIONAL)
If you would like to share more thoughts and information, you may do so here. This is a good
place to mention any cultural or religious views that influence your healthcare goals, values
and preferences.
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7
If you would like to share additional details, please use any of the lined spaces provided at the
end of this document.
PART 3 (OPTIONAL):
Additional Preferences
For help with filling out this section, please refer to Part 3 of the
Step-by-Step Guide (Page 12).
Organ Donation
 I wish to donate any and all organs and tissues.
OR
 I do not wish to donate any of my organs or tissues.
OR
 I wish to donate only the following organs or tissues (please specify):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
My Wishes for After I Die
I have the following wishes regarding funeral, burial and/or cremation arrangements:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
8
PART 4:
How Strictly Do I Want My Advance
Healthcare Directive Followed?
For help with filling out this section, please refer to Part 4 of the
Step-by-Step Guide (Page 13).
I want my goals, values and preferences as written in this directive to:
Please complete the sentence above by initialing either option 1 or option 2:
Option 1
Serve as a general guide, based on what I know now.
___________________
(Initial Here)
OR
Option 2
Be followed strictly, under all circumstances.
___________________
(Initial Here)
If you would like to share more thoughts and information, please use the space
bel
ow:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
If you would like to share additional details, please use any of the lined spaces provided at the
end of this document.
9
PART 5 (OPTIONAL):
Identifying My Physician
For help with filling out this section, please refer to Part 5 of the
Step-by-Step Guide (Page 14).
You may have physicians involved in your care who understand your goals, values and
preferences
. If you would like them to be involved in discussions regarding your condition
and treatment options, please list their names and contact information below.
Name of Physician: _____________________________________________________________________
Phone Number(s) (if known): ___________________________________________________________
Email Address (if known): ______________________________________________________________
Name of Physician: _____________________________________________________________________
Phone Number(s) (if known): ___________________________________________________________
Email Address (if known): ______________________________________________________________
Name of Physician: _____________________________________________________________________
Phone Number(s) (if known): ___________________________________________________________
Email Address (if known): ______________________________________________________________
Please remember also to discuss your values and choices with the physician(s) named above
and provide him/her/them a copy of your directive.
10
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PART 6:
Signing My Advance Healthcare Directive
For help with filling out this section, please refer to Part 6 of the
Step-by-Step Guide (Page 15).
In order to make this document legal and valid, you must sign below
in the presence of EITHER a notary public (Page 13) OR two
witnesses (Page 14):
Name (Print):
_________________________________________________________________________________________
Signature:
_________________________________________________________________________________________
Date of Signature:
_________________________________________________________________________________________
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13
Signing My Advance Healthcare Directive
With a Notary
Note: If you complete the section below, you do not need to complete Page 14.
NOTARIZATION
(California All-Purpose Acknowledgment, Civil Code 1189)
A notary public or other ocer completing this certificate verifies only the identity of
the individual who signed the document to which this certificate is attached, and not
the truthfulness, accuracy or validity of that document.
State of California
County of _____________________________________________
}
On _______________ before me, ____________________________________________________________
Date Here Insert Name and Title of the Ocer
personally appeared _____________________________________________________________________
Name(s) of Signer(s)
_________________________________________________________________________________________
who proved to me on the basis of satisfactory evidence to be
the person(s) whose name(s) is/are subscribed to the within
instrument and acknowledged to me that he/she/they executed
the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the person(s), or
the entity upon behalf of which the person(s) acted, executed
the instrument.
I certify under PENALTY OF PERJURY under the laws of
the State of California that the foregoing paragraph is true
and correct.
WITNESS my hand and ocial seal.
Signature _______________________________________________________________________________
Signature of Notary Public
Place Notary Seal Above
14
Signing My Advance Healthcare Directive
With Witnesses
Note: If you complete the section below, you do not need to complete Page 13.
STATEMENT OF WITNESSES
I declare under penalty of perjury under the laws of California 1) that the individual who signed
or acknowledged this Advance Healthcare Directive is personally known to me, or that the
individual’s identity was proven to me by convincing evidence; 2) that the individual signed or
acknowledged this Advance Healthcare Directive in my presence; 3) that the individual appears
to be of sound mind and under no duress, fraud or undue influence; 4) that I am not a person
appointed as agent by this Advance Healthcare Directive; and 5) that I am not the individual’s
healthcare provider, an employee of an operator of a community care facility, nor the employee
of an operator of a residential care facility for the elderly; and 6) I am over 18 years of age.
WITNESS #1
________________________________________________________________________________________
Signature
of Witness #1 Date
________________________________________________________________________________________
Printed Name of Witness #1 Phone Number
WITNESS #2
________________________________________________________________________________________
Signature
of Witness #2 Date
________________________________________________________________________________________
Printed Name of Witness #2 Phone Number
One of the witnesses also must sign the following declaration:
I further declare under penalty of perjury under the laws of California that I am not related
to the individual ex
ecuting this Advance Healthcare Directive by blood, marriage or
adoption, and, to the best of my knowledge, I am not entitled to any part of the individual’s
estate upon his or her death under a will now existing or by operation of law.
________________________________________________________________________________________
Signature of Witness #1 or #2 Date
________________________________________________________________________________________
Printed Name of Witness #1 or #2 Date
15
Special Witness Requirement
Note: For nursing home or skilled nursing facility patients only, a signature
from a patient advocate or ombudsman is required in addition to completing
either Page 13 or Page 14.
If you are not a nursing home patient or skilled nursing facility patient, you may skip
this section.
STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN
I declare under penalty of perjury under the laws of California that I am a patient advocate or
ombudsman as designated by the State Department of Aging and that I am serving as a witness
as required by Section 4675 of the Probate Code.
________________________________________________________________________________________
Signature of Patient Advocate or Ombudsman Date
________________________________________________________________________________________
Printed Name of Patient Advocate or Ombudsman Phone Number
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© 2019 CEDARS-SINAI 3318 (0119)
Additional Resources
To sign up for the free Advance Care Planning Class, call 800-700-6424.
Cedars-Sinai Supportive Care Medicine, 310-423-9520
Cedars-Sinai’s Supportive Care Medicine (SCM) team helps inpatients and outpatients who are
facing life-limiting or advanced illness to achieve the best possible quality of life, and also provides
support for families. SCM clinicians are experts in managing a full range of symptoms, both physical
and psychological; they are also specifically trained to help with Advance Care Planning and
Advance Healthcare Directives.
Cedars-Sinai Spiritual Care, 310-423-5550; cedars-sinai.org/spiritualcare
Members of the Cedars-Sinai Spiritual Care Department oer spiritual care services to
Cedars-Sinai patients and their loved ones. Chaplains are available to visit patients and help
work through dicult issues related to end-of-life decisions and care.
Cedars-Sinai Center for Healthcare Ethics, 310-423-9636; cedars-sinai.org/ethics
For patients hospitalized at Cedars-Sinai, the center oers clinical ethics consultation. The
aim is to help patients, family members, physicians and other members of the patient care team
examine and discuss pertinent ethical values and goals.
Cedars-Sinai Social Work
Inpatient: 310-423-4446 | Outpatient: 310-248-8311
The following are websites that provide information on advance
healthcare planning:
Advance Health Care Directive Registry—California:
sos.ca.gov/registries/advance-health-care-directive-registry
Aging With Dignity: agingwithdignity.org
American Hospital Association: putitinwriting.org
California Medical Association: cmanet.org
Caring Connections: caringinfo.org
Coalition for Compassionate Care of California: coalitionccc.org and capolst.org
(POLST forms in English and other languages)
Hospice Association of America: hospice.nahc.org
Donate Life California—Organ and Tissue Donor Registry: donatelifecalifornia.org
U.S. Department of Veterans Aairs: losangeles.va.gov/patients/advance.asp
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