9
My Advance Care Plan
Have the TALK leave no doubt with your family about
your healthcare wishes!
Use the attached form to document your healthcare wishes.
Remember that the most important part of making medical choices is to TALK about them!
TALK about your Advance Care Plan with your family and your Healthcare Agents.
TALK about it with your doctor.
If you have questions about making medical choices or completing your Advance Care Plan, call the Sentara Center for
Healthcare Ethics at (757) 252-9550 for assistance.
THE U.S. LIVING WILL REGISTRY
This service is provided by Sentara FREE of charge to our community. You can store your Advance Care Plan on the
Registry so it will be available to any health care provider in Virginia and North Carolina as well as any providers across
the U.S. Once registered, you will receive an acknowledgment along with a wallet card and stickers for your ID cards
that will alert medical professionals that you have an Advance Care Plan on file with the Registry and the 800 number so
they can retrieve it.
If you want to have your document registered, you must complete the U.S. Living Will Registry Registration Agreement,
giving the Registry permission to store your Advance Care Plan and provide it to any healthcare facility that requests a
copy, and attach your Advance Care Plan.
What do I do with my ACP?
1. Make enough copies* and provide one each to:
a. Your appointed Healthcare Agents
b. Family members
c. Doctor
d. The US Living Will Registry through the Sentara Center for Healthcare Ethics***
2. Keep the original yourself in a safe and accessible place.
3. ***Mail a copy of your document to:
The Sentara Center for Healthcare Ethics
4705 Columbus Street, Suite 303
Virginia Beach VA 23462
or fax to our secure line at 757-995-7337
*Copies are the same as the original in Virginia
My Advance Care Plan
Have the TALK leave no doubt with your family about
your healthcare wishes!
Use the attached form to document your healthcare wishes.
Remember that the most important part of making medical choices is to TALK about them!
TALK about your Advance Care Plan with your family and your Healthcare Agents.
TALK about it with your doctor.
If you have questions about making medical choices or completing your Advance Care Plan, call the Sentara Center for
Healthcare Ethics at (757) 252-9550 for assistance.
THE U.S. LIVING WILL REGISTRY
This service is provided by Sentara FREE of charge to our community. You can store your Advance Care Plan on the
Registry so it will be available to any health care provider in Virginia and North Carolina as well as any providers across
the U.S. Once registered, you will receive an acknowledgment along with a wallet card and stickers for your ID cards
that will alert medical professionals that you have an Advance Care Plan on file with the Registry and the 800 number so
they can retrieve it.
If you want to have your document registered, you must complete the U.S. Living Will Registry Registration Agreement,
giving the Registry permission to store your Advance Care Plan and provide it to any healthcare facility that requests a
copy, and attach your Advance Care Plan.
What do I do with my ACP?
1. Make enough copies* and provide one each to:
a. Your appointed Healthcare Agents
b. Family members
c. Doctor
d. The US Living Will Registry through the Sentara Center for Healthcare Ethics***
2. Keep the original yourself in a safe and accessible place.
3. ***Mail a copy of your document to:
The Sentara Center for Healthcare Ethics
4705 Columbus Street, Suite 303
Virginia Beach VA 23462
or fax to our secure line at 757-995-7337
*Copies are the same as the original in Virginia
Street Address
City:
Primary Phone: ( )
Emergency Contact Name:
Address:
Primary Phone:
( )
rev. 1/2017
(Initials)
My Advance Care Plan
Virginia
Communicating my Healthcare Wishes
Name: Social Security Number: XXX – XX -
Address: City: State & ZIP:
Phone: ( ) _ - Date of Birth: - - _
Sentara Healthcare Advance Directive
USLWR Source Code 36901001
Section I
(Cross out any section(s) you do not wish to include in your document.)
If I am unable to make decisions for myself, or unable to communicate my healthcare wishes about treatment, I
appoint the person(s) listed below to be my designated Healthcare Agent(s), who will make my wishes known to
my healthcare providers. I direct my healthcare providers and family to respect and honor my wishes.
Primary Healthcare Agent:
Name: Address:
City: State & ZIP: Cell Phone: ( ) -
Work Phone: ( ) -
Secondary Healthcare Agent:
Name:
Home Phone: ( ) -
Address:
City: State & ZIP: Cell Phone: ( ) -
Work Phone: ( ) - Home Phone: ( ) -
Additional Healthcare agents can be designated on an attached piece of paper; all Agents should be listed in
decision-making order. My Healthcare Agent(s) shall make healthcare decisions based on my previously
expressed wishes, my personal beliefs and values and shall be granted the power to make healthcare decisions as
outlined in the Virginia Healthcare Decisions Act, 54.1-2984.
If I initial this line, my agent WILL have the authority to restrict visitors in a healthcare facility.
(Initials)
Section II - Anatomical Gift (whole body) or Organ Donation:
_____ I wish to be an Organ Donor OR Anatomical Donor (whole body)
(Initials)
If I am not already registered as an anatomical donor, I appoint the following person to make these arrangements on
my behalf:
Name: Phone: ( ) -
Address: City: State & ZIP:
SENT
AR
A
®
H E A l T H C A A
U.S. Living Will Registry® Registration Agreement
SOURCE CODE: 36901001
Suffix
(4 digits)
Registrant's Identifying Information (Please print clearly)
Name: First Middle Last
Social Security#
XXX
-
XX
-
Date of Birth Month
Day Year
Email address for Registrant or Emergency Contact:
* Annual update reminders will be sent via email (email addresses will not be shared or sold)
Apt #
State: Zi p Code :
Alternate Phone:( )
Relationship:
Alternate Phone: ( )
I, ("Registrant" or "I"), authorize U.S. Living Will Registry®, with offices at 808 South Ave. West,
P.O. Box 2789 Westfield, NJ 07091-2789 ("Registry"), to electronically store a copy ofmy advance directive(s) provided to Registry
with this registration form or subsequently, including but not limited to a living w ill, health care proxy, durable power of attorney for
health car e and/or finan cial matters, M edical or Physician Orders for Scope of Treatment (POST) organ donation wishes and
emer gency contact inf ormation ("Adv ance Dir ectives"). I further authorize the Registry to make available a copy of the stored
Advance Directive(s) to any health care provider or other person believed charged with giving effect to my Advance Directive(s) or
assisting in same, who requests it in conjunction with my care, provided such a request is consistent with the Registry's policies and
procedures, or as deemed advisable by the Registry in an emergency situation, or as req uir ed by law. The Ad van ce Dir ective(s) that I
am providing is my current, effective Advance Directive(s), and w as s igned and witnessed in accordance with the law of the state of
my residence.
I hereby authorize Registry to make available a copy ofmy Advance Directive(s) to hospitals, physicians, or other health care providers
involved with my care, or anyone who has access to the wallet identification ("ID") card provided to me by Registry. I understand this
authorization is voluntary. I agree to notify Registry immediately ifl decide to revoke or change my Advance Directive(s) stored with
Registry and to provide Registry with a copy of any additional Advance Directive(s) that I sign. I understand that unless I tenninate
this authorization or inform Registry of revocation or changes to my Advance Directive(s), the Advance Directive(s) stored w it h
Registry will be provided to health care providers in accord with Registry policies and practices.
I understand that Registry makes no representations about the validity of my Advance Directive(s) under federal or state law and that
Registry bears no responsibility for the actions taken by health care providers in relation to my Advance Directive(s). I hereby waive
any and all legal claims against Registry for the actions and o missions by any health care providers who receive a cop y of my Advance
Directive(s) from Registry and for any damages arising from the transmission or disclosure of the Advance Directive(s) I provide to
Registry. Registry shall not be liable for the loss, destruction or unavailability of all or part of my Advance Dire ctive(s).
I understand that I may revoke this authorization at any time by giving written notice of my revocation to Regist ry. This Agreement
will remain in force until revoked by me or until terminated in accordance with the agreement between me and Registry or until
registration is cancelled pursuant to the Registry ' s policies and procedures. When the Agreement is terminated, I understand that
Registry will remove my Advance Directive(s) from its file s.
I understand that anyone who gains access to my wallet ID card provided by Registry can use it to gain access to my Advance
Directive(s) and personal information stored with Registry, and I will not hold the Registry liable for such authorized or unauthorized
access.
I hereby agree to the terms set forth here in .
X
-----------------------------
Signature of Registrant
DATED: I I
--
- -
rev. 1/2017
(Initials)
My Advance Care Plan
Virginia
Communicating my Healthcare Wishes
Name: Social Security Number: XXX – XX -
Address: City: State & ZIP:
Phone: ( )
-
Date of Birth: - - _
Sentara Healthcare Advance Directive
USLWR Source Code 36901001
Section I
(Cross out any section(s) you do not wish to include in your document.)
If I am unable to make decisions for myself, or unable to communicate my healthcare wishes about treatment, I
appoint the person(s) listed below to be my designated Healthcare Agent(s), who will make my wishes known to
my healthcare providers. I direct my healthcare providers and family to respect and honor my wishes.
Primary Healthcare Agent:
Name: Address:
City: State & ZIP: Cell Phone: ( ) -
Work Phone: ( ) -
Secondary Healthcare Agent:
Name:
Home Phone: ( ) -
Address:
City: State & ZIP: Cell Phone: ( ) -
Work Phone: ( ) - Home Phone: ( ) -
Additional Healthcare agents can be designated on an attached piece of paper; all Agents should be listed in
decision-making order. My Healthcare Agent(s) shall make healthcare decisions based on my previously
expressed wishes, my personal beliefs and values and shall be granted the power to make healthcare decisions as
outlined in the Virginia Healthcare Decisions Act, 54.1-2984.
If I initial this line, my agent WILL have the authority to restrict visitors in a healthcare facility.
(Initials)
Section II - Anatomical Gift (whole body) or Organ Donation:
_____ I wish to be an Organ Donor OR Anatomical Donor (whole body)
(Initials)
If I am not already registered as an anatomical donor, I appoint the following person to make these arrangements on
my behalf:
Name: Phone: ( ) -
Address: City: State & ZIP:
SENT AR
A
®
H E A l T H C A A
U.S. Living Will Registry® Registration Agreement
SOURCE CODE: 36901001
Registrant's Identifying Information (Please p rint clearly )
Name: First M iddle L
ast Suffix
Social Security#
XXX
-
XX
-
_ Date of Birth M onth
Day Year (4 digits)
Email addre ss for R
egistrant or Emergency Contact:
* Annual update reminders will be sent via email (email addresses will not be shared or sold)
Street Addre ss Apt #
_
City: State: Zi p Code:
_
Primary Phone:
(,_
_,
_
_
Alternate Phone: (
_
Emergency Contact Name: Relationship:
_
Address:
_
Prima
ry Phone: (
, _ _
Alternate Phone: (
_
I, ("Registrant" or "I"), authorize U.S. Living Will Registry®, with offices at 808 South Ave. West,
P.O. Box 2789 Westfield, NJ 07091-2789 ("Registry"), to electronically store a copy ofmy advance directive(s) provided to Registry
with this registration form or subsequently, including but not limited to a living will, health care proxy, durable power of attorney for
health car e and/or finan cial matters, M edical or Physician Orders for Scope of Treatment (POST) organ donation wishes and
emer gency contact inf ormation ("Adv ance Dir ectiv es"). I further authorize the Registry to make available a copy of the stored
Advance Directive(s) to any health care provider or other person believed charged with giving effect to my Advance Directive(s) or
assisting in same, who requests it in conjunction with my care, provided such a request is consistent with the Registry's policies and
procedures, or as deemed advisable by the Registry in an emergency situation, or as req uir ed by law. Th e Ad van ce Dir ective(s) that I
am providing is my current, effective Advance Directive(s), and w as s igned and witnessed in accordance with the law of the state of
my residence.
I hereby authorize Registry to make available a copy ofmy Advance Directive(s) to hospitals, physicians, or other health care providers
involved with my care, or anyone who has access to the wallet identification ("ID") card provided to me by Registry. I understand this
authorization is voluntary. I agree to notify Registry immediately ifl decide to revoke or change my Advance Directive(s) stored with
Registry and to provide Registry with a copy of any additional Advance Directive(s) that I sign. I understand that unless I tenninate
this authorization or inform Registry of revocation or changes to my Advance Directive(s), the Advance Directive(s) stored w it h
Registry will be provided to health care providers in accord with Registry policies and practices.
I understand that Registry makes no representations about the validity of my Advance Directive(s) under federal or state law and that
Registry bears no responsibility for the actions taken by health care providers in relation to my Advance Directive(s). I hereby waive
any and all legal claims against Registry for the actions and o missions by any health care providers who receive a copy of my Advance
Directive(s) from Registry and for any damages arising from the transmission or disclosure of the Advance Directive(s) I provide to
Registry. Registry shall not be liable for the loss, destruction or unavailability of all or part of my Advance Dire ctive(s).
I understand that I may revoke this authorization at any time by giving written notice of my revocation to Regist ry. This Agreement
will remain in force until revoked by me or until terminated in accordance with the agreement between me and Registry or until
registration is cancelled pursuant to the Registry ' s policies and procedures. When the Agreement is terminated, I understand that
Registry will remove my Advance Directive(s) from its file s.
I understand that anyone who gains access to my wallet ID card provided by Registry can use it to gain access to my Advance
Directive(s) and personal information stored with Registry, and I will not hold the Registry liable for such authorized or unauthorized
access.
I hereby agree to the terms set forth here in .
X
-----------------------------
Signature of Registrant
DATED: I I
My Advance Care Plan Virginia
COMMUNICATING MY HEALTHCARE WISHES
rev. 1/2017
Section III - Specific Healthcare Instructions:
In this section, you can indicate your preferences for life-sustaining treatments in certain situations.
(Examples of life-sustaining treatments are CPR (cardiopulmonary resuscitation), a breathing
machine, kidney dialysis, and a feeding tube). You may choose to complete all, some, or none of this
section as you deem appropriate.
Choose only one box for each statement:
life sustaining
treatments;
allow me to
I’m not sure;
it would depend on
the circumstances.
Discuss with my
healthcare agent.
Yes,
I would want life-
sustaining
treatments as long
as appropriate
If I am unconscious, in a coma, or in a vegetative
state and there is little or no chance of recovery…
(Initials) (Initials) (Initials)
If I have permanent, severe brain damage that
makes me unable to recognize my family or friends
(i.e. severe dementia, damage from stroke)…
(Initials) (Initials) (Initials)
If I have a permanent condition where others must
help me with my daily needs (such as eating and
toileting)…
(Initials)
(Initials)
If I have to be in bed and use a breathing machine
24/7 for the rest of my life
(Initials)
(Initials)
If I have severe pain or other severe symptoms that
cause suffering and can’t be relieved…
(Initials) (Initials) (Initials)
If I have a condition that will result in death soon,
even with life-sustaining treatments
(Initials) (Initials) (Initials)
NOTE: Regardless of your choices above, you will still receive treatment to relieve pain and make you comfortable.
Additional Instructions/Preferences
If you have attached additional pages, please initial beside any of the following as applicable:
Patient Protest (must be signed by physician)
(Initials)
(can be found at www.sentara.com/advancedirectives)
Life-Sustaining Treatment During Pregnancy (can be found at www.sentara.com/advancedirectives)
(Initials)
Other attached pages
(Initials)
Section IV
By signing below, I indicate that I understand this document and I am willingly and voluntarily executing it.
I also understand that I may revoke all or any part of it at any time as provided by law.
My signature (required) Date
TWO WITNESS SIGNATURES REQUIRED
Print Name:
Print Name:
Signature:
Signature:
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