Fill - Free fillable My Health Care Directive (Allina Health) PDF form

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My Health Care Directive

Legal name: _________________________________________ Date of birth: _______________________

Address: _________________________________________________________________________________

Telephone: (Home) _________________________________ (Cell) ________________________________

My health care directive was created to guide my health care agent and family, friends or others

close to me to make health care decisions on my behalf if illness or injury prevents me from deciding

or communicating them myself.

I understand that my health care agent and my health care provider(s) may not be able to honor

my wishes, goals and values in every circumstance.

Any health care directive document created before this is no longer valid.

My Health Care Agent

I have chosen a health care agent to speak for me if:

 I am unable to communicate my wishes, goals and values, and health care decisions due to illness

or injury

 my health care providers have determined I am not able to make my own health care decisions.

When choosing a health care agent, I have considered his or her ability to willingly make decisions

based on my choices. I trust this person to follow my wishes, goals and values under times of stress.

I understand that my health care agent must be 18 years of age or older.

My primary (main) health care agent is:

Name: ___________________________________________ Relationship: ___________________________

Address: _________________________________________________________________________________

Telephone (Home) ____________________ (Cell) ____________________ (Work) ___________________

patient sticker

NAME, DOB, MRN

MINNESOTA

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Alternate health care agent

I choose this person as my alternate health care agent if my primary health care agent is not available

or willing to serve as my health care agent:

Name: ___________________________________________ Relationship: ___________________________

Address: _________________________________________________________________________________

Telephone (Home) ____________________ (Cell) ____________________ (Work) ___________________

Powers of my health care agent

My health care agent automatically has all of the following powers when I am unable to make my

own health care decisions:

 Make decisions about my health care, including decisions to start, stop or change treatments

for me. This includes taking out or not putting in tube feedings, tests, medicine, surgery, and

other decisions about treatments including mental health treatments or medicines. If treatment

has already begun, my health care agent can continue or stop it based on verbal and/or written

instructions.

 Interpret any instructions in this document according to his or her understanding of my wishes,

goals and values.

 Review and release my medical records, health information and other personal records as needed

for my health care as a personal representative under the Health Insurance Portability and

Accountability Act of 1996 (HIPAA) and any similar state law.

 Arrange for my health care and treatment in any state or location he or she thinks is appropriate.

 Decide which health care providers and organizations provide my care and treatment.

Note: Your health care agent cannot make decisions about your ﬁnances. Consider talking with a

lawyer about ﬁlling out a Financial Power of Attorney document if you would like to make sure you

give someone power to make ﬁnancial decisions or complete ﬁnancial transactions on your behalf.

Additional powers of my health care agent

If I want my health care agent to have any of the following powers, I have initialed the box(es) below.

Make decisions about the care of my body after death.

Continue as my health care agent even if our marriage or domestic partnership is legally

ending or has been ended.

If I am pregnant, determine whether to attempt to continue my pregnancy to delivery

based upon his or her understanding of my wishes, goals, values and instructions.

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NAME, DOB, MRN

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Cardiopulmonary Resuscitation (CPR)

Cardiopulmonary resuscitation (CPR) is a treatment used to attempt to restore heart rhythm and

breathing when they have stopped. It may include chest compressions (forceful pushing on the chest

to make the blood circulate), medicines, electrical shocks, a breathing tube and a hospital stay.

I understand that:

 CPR can save a life but it does not always work

 CPR does not work as well for people who have chronic (long-term) diseases

 recovery from CPR can be painful and difﬁcult.

Note: Make this choice based on your health today. You can always update your health care directive

as you age or your health changes.

I have initialed the option I prefer for this situation. My choice about CPR is:

I want CPR attempted if my heart or breathing stops in all circumstances.

I want CPR attempted if my heart or breathing stops except when my health care provider

has determined that I have little or no reasonable chance of survival even with CPR.

I do not want CPR attempted if my heart or breathing stops. I prefer a natural death.

If I choose this option, I should talk with my health care provider.

Treatments to Extend My Life

If my health care providers determine I am in a vegetative state, or that I have a permanent brain

injury that means it is very likely I will not regain consciousness or recover my ability to know who

I am, I choose the following.

Note: Make this choice based on your health in the future. You can always update your health care

directive as you age or your health changes.

I have initialed the option I prefer for this situation. My choice is:

I would want to stop or withhold all treatments that are extending my life at this time.

This includes, but is not limited to, tube feedings, IV (intravenous) ﬂuids, respirator/

ventilator (breathing machine), CPR and antibiotics (medicines).

I would want all the treatments recommended by my health care team until they agree

that such treatments are harmful and no longer helpful. This includes, but is not limited to,

tube feedings, IV ﬂuids, respirator/ventilator, CPR and antibiotics.

I would want to receive limited treatment. I would want to receive certain types of care in

certain circumstances, as I’ve written below. For example, you may write that you want to

live on life support until all of your family has arrived.

______________________________________

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NAME, DOB, MRN

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Organ Donation

Organ donation is donating organs, eyes, tissues or any other body part to other people in need.

I have initialed the option I prefer for this situation.

I do not want to donate my organs, eyes, tissues or any other body parts. I do not allow

this donation after I die.

I do want to donate any or all of my organs, eyes, tissues or other body parts. I allow this

donation after I die. My health care agent is authorized to start or continue supportive

treatments or any interventions needed to maintain my organs, eyes, tissues or any other

body part until donation has been completed.

I do want to donate, but I want to limit my tissue and organ donations. I authorize the

limited donation, as I’ve written below, after I die. My health care agent is authorized to

start or continue supportive treatments or any interventions needed to maintain my organs,

eyes, tissues or any other body part until donation has been completed.

_________________________________________________________________________________

I have not decided whether to donate any or all of my organs, eyes, tissues or other

body parts. I authorize my health care agent to make this decision after I die.

Values and Beliefs

The things that make life most worth living to me are:

__________________________________________________________________________________________

Pain Management Values

My thoughts on how pain management affects my quality of life:

__________________________________________________________________________________________

Religious Afﬁliation

I am of the __________________________ faith, and am a member of the _____________________ faith

community in (city) ______________________________________. Please try to notify them of my death

and arrange for them to provide my funeral/memorial.

I prefer to be buried/cremated. (circle one)

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NAME, DOB, MRN

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Making My Health Directive Valid

Under Minnesota law, you must sign and date this document in Minnesota in front of a notary public

or two witnesses.

 Your notary or witnesses cannot be someone who is named as a health care agent in this document.

 Your notary cannot be a health care provider (but can be an employee of a health care provider)

caring for you at the time you sign this document.

 If you sign before two witnesses, only one of the two witnesses can be a health care provider

(or an employee of a health care provider) caring for you at the time you sign this document.

Important: Wait to sign your name until you are in front of either a notary public or two witnesses.

The signature dates must match.

I have made this document willingly. I am thinking clearly. This document expresses my

choices about my health care decisions:

Signature: ____________________________________________________ Date: _______________________

If I cannot sign my name, I ask the following person to sign for me:

Signature: ________________________________________________________________________________

Print name: __________________________________________________ Date: _______________________

The reason I cannot sign my name is: ________________________________________________________

Option 1: Notary public

In my presence on _____________ (date), ________________________________

(name of person completing this health care directive) acknowledged his

or her signature on this document or acknowledged that he or she authorized

the person signing this document to sign on his or her behalf. I am not named

as a health care agent or alternate health care agent in this document.

County of: ___________________________________________________________

(where document is signed)

Witness my hand and seal:

Notary signature: _________________________________________________________________________

My commission expires (date): ______________________________________________________________

Notary stamp:

Important

If you use a

notary public,

you do not need

two witnesses.

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NAME, DOB, MRN

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Option 2: Two witnesses

I declare that:

 this document was signed in my presence by the person completing this

document or by an individual that the person completing this document

authorized to sign on his or her behalf

 I am at least 18 years of age

 I am not named as a health care agent in this document.

Note: Only one of the two witnesses can be a health care provider (or an employee of a health care

provider) caring for you at the time you sign this document.

Signature of Witness 1:

Signature: _____________________________________________________ Date: ______________________

Print name: _______________________________________________________________________________

Address: _________________________________________________________________________________

Are you a health care provider (or employee of a health care provider) giving direct care to the person

creating this health care directive? q yes q no

Signature of Witness 2:

Signature: _____________________________________________________ Date: ______________________

Print name: _______________________________________________________________________________

Address: _________________________________________________________________________________

Are you a health care provider (or employee of a health care provider) giving direct care to the person

creating this health care directive? q yes q no

Important

If you use two

witnesses, you

do not need a

notary public.

OTHER TRADEMARKS USED ARE OWNED BY THEIR RESPECTIVE OWNERS

THIS FACT SHEET DOES NOT REPLACE MEDICAL OR PROFESSIONAL ADVICE; IT IS ONLY A GUIDE.

gen-ah-18051 (9/17)

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