REGISTRATION FORM
Instructions: Please complete the information requested below and mail to the address
listed above. A registry card containing an file number and password will be sent to
you. Please carry the card with you at all times and furnish the file number and
password to persons who need to be aware of your directives, such as family members
and health care providers.
PLEASE TYPE OR PRINT. COMPLETE LINES 1 THROUGH 4.
1. Registrant’s Name (exactly as in document): ___________________________
2. Social Security #: (OPTIONAL**)_____________________________________
3. Registrant’s Mailing Address:________________________________________
4. City: _____________________________________ Zip___________________
If you are an attorney filing on behalf of the Registrant above, please provide your
name and mailing address should you wish the documents returned to your
attention.
Attorney’s Name: _____________________________________________
Attorney’s Mailing Address: _____________________________________
City _________________________________________ Zip ____________
The fee for each directive to be registered is $10.00.
Check the directive you have enclosed with this form:
A health care power of attorney;
A declaration of a desire for a natural death;
An advance instruction for mental health treatment; or
A declaration of an anatomical gift.
**The Advance Health Care Directive Registration requests submission of the social
security number as a part of the confidential registration process. Please note that
while we request this data, all health care directives and social security numbers are
unavailable to the public. Provision of the social security number will allow anyone
who has your unique identifying code and password to have access to any and
all documents you file with this agency. If you choose not to provide the social
security number, then you will be provided a wallet size card with a unique identifying
number and password for each document you file.
NORTH CAROLINA SECRETARY OF STATE
Advance Health Care Directive Registry
P. O. Box 29622
Raleigh, NC 27626-0622
https://www.sosnc.gov
