Form 10-0137 VA Advance Directive - Durable Power of Attorney for Hea

OMB Approval Number 2900-0556
Estimated Burden Avg: 30 minutes
Expiration Date: 10/31/2017

VA ADVANCE DIRECTIVE
DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
This advance directive form is an official document where you can write down your preferences for your
health care. If someday you can’t make health care decisions for yourself anymore, this advance directive
can help guide the people who will make decisions for you.
You can use this form to:
 Name specific people to make health care decisions for you
 Describe your preferences for how you want to be treated
 Describe your preferences for medical care, mental health care, long-term care, or other types of health
care
When you complete this form, it’s important that you also talk to your doctor, family, and other loved ones
who may help to decide about your care. You should explain what you meant when you filled out the form.
A health care professional can help you with this form and can answer any questions that you have. If you
need more space for any part of the form, you may attach extra pages. Be sure to initial and date every page
that you attach.
PART I: PERSONAL INFORMATION
NAME (Last, First, Middle):

LAST FOUR DIGITS OF SSN:

STREET ADDRESS:

CITY, STATE, ZIP:

HOME PHONE WITH AREA CODE:

WORK PHONE WITH AREA CODE:

MOBILE PHONE WITH AREA CODE:

Privacy Act Information and Paperwork Reduction Act Notice
The information requested on this form is solicited under the authority of 38 C.F.R. §17.32. It is being collected to document
your preferences for your health care in the event that you can’t speak for yourself anymore. The information you provide
may be disclosed outside the VA as permitted by law. Possible disclosures include those that are described in the “routine
uses” identified in the VA system of records 24VA10P2, Patient Medical Records-VA, published in the Federal Register in
accordance with the Privacy Act of 1974. This is also available in the Compilation of Privacy Act Issuances at. You may
choose to fill out this form or not. But without this information, VA health care providers may not understand your
preferences as well. If you don’t fill out this form, there won’t be any effect on the benefits you are entitled to receive. The
Paperwork Reduction Act of 1995 requires us to let you know that this information collection follows the clearance
requirements of section 3507 of this Act. We estimate that it will take you about 30 minutes to fill out this form, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the information you write down. A Federal agency may not conduct or sponsor, and a person is not required
to respond to a collection of information, unless it displays a current valid OMB control number. The OMB Control No. for
this information collection is 2900-0556.
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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
LAST FOUR DIGITS OF SSN:

NAME (Last, First, Middle)

PART II: DURABLE POWER OF ATTORNEY FOR HEALTH CARE
This section of the advance directive form is called a Durable Power of Attorney for Health Care. It lets you
appoint a specific person to make health care decisions for you in case you can’t make decisions for
yourself anymore. This person will be called your Health Care Agent.
Your Health Care Agent should be someone:
 You trust
 Who knows you well
 Who is familiar with your values and beliefs
If you get too sick to make decisions for yourself, your Health Care Agent will have the authority to make all
health care decisions for you. This includes decisions to admit and discharge you from any hospital or other
health care institution. Your Health Care Agent can also decide to start or stop any type of health care
treatment. He or she can access your personal health information, and medical records, including
information about whether you have been tested for HIV or treated for AIDS, sickle cell anemia, substance
abuse or alcoholism.
NOTE: If you wish to give general permission for VA to share your medical records or health information
with others, you can complete VA Form 10-5345 (Request for and Authorization to Release Medical
Records or Health Information). You can get VA Form 10-5345 from your VA health care provider or you can
get it using a computer from this website http://www4.va.gov/vaforms/medical/pdf/vha-10-5345-fill.pdf.
A - HEALTH CARE AGENT

Place your initials in the box next to your choice. Choose only one.
Initials

Initials

I don't wish to appoint a Health Care Agent right now.
(Skip this section and go to Part III, Living Will.)
I appoint the person named below to make decisions about my health care if I can't decide for myself
anymore.
Relationship to Me:

Name (Last, First, Middle):

Street Address:

Home Phone with Area Code:

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City, State, Zip:

Work Phone with Area Code:

Mobile Phone with Area Code:

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

LAST FOUR DIGITS OF SSN:

B - ALTERNATE HEALTH CARE AGENT

Fill out this section if you want to appoint a second person to make health care decisions for you,
in case the first person isn’t available.
Initials

If the person named above can't or doesn't want to make decisions for me, I appoint the person
named below to act as my Health Care Agent.

Name (Last, First, Middle):

Relationship to Me:

City, State, Zip:

Street Address:

Home Phone with Area Code:

Work Phone with Area Code:

Mobile Phone with Area Code:

PART III: LIVING WILL
This section of the advance directive form is called a Living Will. This section of it lets you write down how
you want to be treated in case you aren't able to decide for yourself anymore. Its purpose is to help others
decide about your care.
A - SPECIFIC PREFERENCES ABOUT LIFE-SUSTAINING TREATMENTS

In this section, you can indicate your preferences for life-sustaining treatments in certain situations. Some
examples of life-sustaining treatments are:





CPR (cardiopulmonary resuscitation)
a breathing machine (mechanical ventilation)
kidney dialysis
a feeding tube (artificial nutrition and hydration)

Think about each situation described on the left and ask yourself, “In that situation, would I want to have
life-sustaining treatments?” Place your initials in the box that best describes your treatment preference. You
may complete some, all, or none of this section. Choose only one box for each statement.

If I am unconscious, in a coma, or in a vegetative
state and there is little or no chance of recovery.
If I have permanent, severe brain damage that
makes me unable to recognize my family or friends
(for example, severe dementia).
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Yes.
I would want
life-sustaining
treatments.

I'm not sure. It
would depend
on the
circumstances.

No.
I would not want
life-sustaining
treatments.

Initials

Initials

Initials

Initials

Initials

Initials

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

LAST FOUR DIGITS OF SSN:

Yes.
I would want
life-sustaining
treatments.

I'm not sure. It
would depend
on the
circumstances.

No.
I would not want
life-sustaining
treatments.

If I have a permanent condition where other people
must help me with my daily needs (for example,
eating, bathing, toileting).

Initials

Initials

Initials

If I need to use a breathing machine and be in bed
for the rest of my life.

Initials

Initials

Initials

If I have pain or other severe symptoms that cause
suffering and can't be relieved.

Initials

Initials

Initials

If I have a condition that will make me die very soon,
even with life-sustaining treatments.

Initials

Initials

Initials

Initials

Initials

Initials

Other:

B - MENTAL HEALTH PREFERENCES

This section is optional. You may skip this section if you do not have a serious mental health problem or if you
do not want to write down your preferences for mental health care. If you have a serious mental health
condition, you might want to write down medications that have worked for you in the past and that you would
want again, or you might want to write down the mental health facilities or hospitals that you like and those
that you don’t like. If you need more space, you may attach extra pages and use this space to refer to
attached pages. Be sure to initial and date every page that you attach.

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

LAST FOUR DIGITS OF SSN:

C - ADDITIONAL PREFERENCES

This section is optional. In this space, you can write other important preferences for your health care that
aren’t described somewhere else in this document. For example, these might be social, cultural, or
faith-based preferences for care, or preferences about treatments such as feeding tubes, blood transfusions,
or pain medications. If you need more space, you may attach extra pages and use this space to refer to
attached pages. Be sure to initial and date every page that you attach.

D - HOW STRICTLY YOU WANT YOUR PREFERENCES FOLLOWED

Place your initials in the box next to the statement that reflects how strictly you want others to follow your
preferences. Choose only one.
Initials

I want my preferences, as expressed in this Living Will, to serve as a general guide. I understand
that in some situations, the person making decisions for me may decide something different from the
preferences I express above, if they think it's in my best interests.

Initials

I want my preferences, as expressed in this Living Will, to be followed strictly, even if the person
making decisions for me thinks that this isn't in my best interests.
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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

LAST FOUR DIGITS OF SSN:

PART IV: SIGNATURES
A - YOUR SIGNATURE
By my signature below, I certify that this form accurately describes my preferences.
DATE

SIGNATURE

B - WITNESSES' SIGNATURES

Two people must witness your signature. VA employees may be witnesses if they are members of:
 The Chaplain Service
 The Social Work Service
 Nonclinical employees (e.g., Medical Administration Service, Voluntary Service, or Environmental
Management Service)
Other employees of your VA facility may not sign as witnesses to your advance directive unless they’re in your family.
Witness #1
I personally witnessed the signing of this advance directive. I am not appointed as Health Care Agent in this
advance directive. I am not financially responsible for the care of the person making this advance directive.
To the best of my knowledge, I am not named in the person’s will.
SIGNATURE:

DATE:

Name (Printed or Typed):

Street Address:

City, State, Zip:

Witness #2
I personally witnessed the signing of this advance directive. I am not appointed as Health Care Agent in this
advance directive. I am not financially responsible for the care of the person making this advance directive.
To the best of my knowledge, I am not named in the person's will.
SIGNATURE:

DATE:

Name (Printed or Typed):

Street Address:

City, State, Zip:

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)

LAST FOUR DIGITS OF SSN:

PART V: SIGNATURE AND SEAL OF NOTARY PUBLIC (Optional)
This VA Advance Directive form is valid in VA facilities without being notarized. However, you may need to
have it notarized to be legally binding outside the VA health care setting. Space for a Notary's signature and
seal is included below.

On this

day of

, in the year of

, personally appeared before
,

me
known by me to be the person who completed this document and acknowledged it as their free act
and deed. IN WITNESS WHEREOF, I have set my hand and affixed my official seal in the County
, State of

of
Notary Public

, on the date written above.
Commission Expires

[SEAL]

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