My Advance Care Plan
“Communicating My Healthcare Wishes”
Patient Protest A
ttachment
If you wish to include the below statement in your Advance Care Plan (Advance Directive), a physician’s signature is
required by law, noting that you are capable of making an informed the decision at the time that you signed this Directive.
Name: _____________________________ Social Security Number: XXX – XX - ________
Address: __________________________ City: ______________ State & ZIP: __________
Phone: (______) _______ - ___________ Date of Birth: _______ - _______ - ___________
Sentara Healthcare Advance Directive
USLWR Source Code 36901001
Date: _________________ 20_____
MY AGENT’S AUTHORITY IN THE EVENT OF MY PROTEST:
My Healthcare Agent(s) may authorize my admission to a healthcare facility for the treatment of mental illness even over
my protest.
My
Healthcare Agent(s) may authorize the specific types of healthcare identified in this Advance Directive, EXCEPT
______________________________, even over my protest.
My physician or licensed clinical psychologist hereby attests that I am capable of making an informed decision and that I
understand the consequences of this provision of my Advance Care Plan.
______________________________________________________________________________________
Physician Signature (required) Date
______________________________________________________________________________________
Physician Name (PRINT) Phone Number
______________________________________________________________________________________
My signature (required) Date
TWO WITNESS SIGNATURES REQUIRED
Print Name: ______________________________ Signature: ____________________________________
Print Name: ______________________________ Signature: ____________________________________
NOTE: This attachment is intended to be part of your Advance Care Plan (Advance Directive). Please initial the
appropriate box on your Advance Care Plan to indicate it is your intention for this attachment to be included in your
Advance Care Plan.
08/2019
