MAKE THE DOCUMENT WORK FOR YOUR SITUATION
About this health care power of attorney planning draft
Choose a health care representative, backups, authority limits, care values, and distribution instructions for a state advance directive. This editable template brings the key details into one document: your identity & family, health care representatives, authority, values & communication, clinical contacts & copies, execution plan & document custody. Complete it online, compare the live preview with your records, and download a blank or completed PDF or editable Word document.
What the template includes
The online builder and downloaded documents use the same fields. A selected state can add relevant research prompts. Complete only applicable items; add explanations for exceptions rather than assuming a blank entry resolves them.
Document details4 inputs +
Set the date, jurisdiction, and your internal reference.
- Document date *
- US state *
- County
- Document reference
Your identity & family9 inputs +
Identify the person making the plan and anyone affected by it.
- Your full legal name *
- Prior names
- Date of birth
- Home address *
- Marital status
- Spouse or partner name
- Children, dates of birth, and relationships
- Other dependents and care needs
- Citizenship or cross-border considerations
Health care representatives8 inputs +
Select someone willing to follow your wishes and able to be reached.
- Primary representative full name *
- Representative address *
- Representative phone *
- Representative email
- First alternate and contacts *
- Second alternate and contacts
- Employment or relationship eligibility concerns
- People to consult without giving them decision authority
Authority, values & communication12 inputs +
Use this as a conversation record for your clinician and final official form.
- Requested scope of authority *
- Specific limits *
- Personal values and acceptable outcomes *
- General treatment preferences
- Artificial nutrition and hydration preferences for clinical discussion
- Comfort and pain-management priorities
- Donation preferences and registration status
- Religious or cultural preferences
- Preferred care setting
- Health record access instructions
- Capacity determination questions
- Existing advance directives and orders
Clinical contacts & copies5 inputs +
Make the final directive available where care is delivered.
- Primary physician and contact
- Usual hospital
- Specialist contacts
- Copies to give to agents and clinicians
- State registry arrangements if available
Execution plan & document custody9 inputs +
Record a plan for the final state-compliant instrument. These fields do not certify validity.
- Planned legal reviewer
- Proposed witness 1 name and contact
- Proposed witness 2 name and contact
- Witness eligibility checks
- Notary or acknowledgment arrangements
- Required notices or statutory wording to verify
- Where the original will be kept
- People and institutions to receive copies
- Next review date
How to complete it
1. Document details
Set the date, jurisdiction, and your internal reference. Review document date, us state, county, document reference against your source records.
2. Your identity & family
Identify the person making the plan and anyone affected by it. Review your full legal name, prior names, date of birth, home address and the remaining details against your source records.
3. Health care representatives
Select someone willing to follow your wishes and able to be reached. Review primary representative full name, representative address, representative phone, representative email and the remaining details against your source records.
4. Authority, values & communication
Use this as a conversation record for your clinician and final official form. Review requested scope of authority, specific limits, personal values and acceptable outcomes, general treatment preferences and the remaining details against your source records.
5. Clinical contacts & copies
Make the final directive available where care is delivered. Review primary physician and contact, usual hospital, specialist contacts, copies to give to agents and clinicians and the remaining details against your source records.
6. Execution plan & document custody
Record a plan for the final state-compliant instrument. These fields do not certify validity. Review planned legal reviewer, proposed witness 1 name and contact, proposed witness 2 name and contact, witness eligibility checks and the remaining details against your source records.
Practical tips
- A financial agent and a health care representative can be different people.
- Advance directives are separate from a clinician-signed POLST or DNR order.
Before signing or submitting
This is a planning and attorney-review draft, not an execution-ready statutory form. It has not been reviewed by a lawyer. State law can require particular wording, notices, witnesses, notarization, capacity, disclosures, or court procedures. Use the linked official form when appropriate and obtain jurisdiction-specific review before signing.