Before you sign: advance health care directive checklist
A printable from Advance Health Care Directive. Fill it in by hand. Nothing you write is collected by this website.
Before you sign: advance health care directive checklist
My choices
- I asked my agent and they said yes. Agent: ____________ Phone: ____________
- First alternate: ____________ Phone: ____________
- Second alternate: ____________ Phone: ____________
- I talked with my agent about my wishes and my faith or values.
- My agent is not my doctor and does not work where I get care.
Signing
- I am 18 or older and making this choice freely.
- The form is dated.
- I signed it (or another adult signed for me, in front of me, as I asked).
- Two witnesses signed, OR a notary signed.
- Neither witness is my agent or my health care provider or works for my provider.
- At least one witness is not related to me and will not inherit from me, and signed the extra statement.
- If I live in a skilled nursing facility: the patient advocate or ombudsman signed as a witness.
After signing
- Copies given to: agent, alternates, doctor, hospital or clinic, family
- Original kept at: ____________
- Optional: registered with the Secretary of State (Form SFL 461, $10, mail only)
Do not write your Social Security number or immigration status on this sheet.
From Advance Health Care Directive. Facts checked October 21, 2026. Free information, not legal or medical advice.