Page-by-page Guide to the Advance Health Care Directive

Ready to complete the form? These pages provide tips and instruction for each page. You may choose to print the form and complete with a pen. Or if you'd rather type into the form, save it to your computer and type into the fields. To save the completed form from a browser window, choose File > Save As and rename the file. Note: If you do not rename the file it WILL NOT save the information you enter.

Download Advance Health Care Directive

  • Advance Health Care Directive

    Advance Health Care Directive

    At this time, we only accept the Advance Health Care Directive on paper.

    Please download the form and fill out with a pen. Or you may save it locally to your computer, and type into the fields.

    Download Advance Health Care Directive now.

  • Introduction – Page 2

    Introduction – Page 2

    2-ALearn more about our approach to Life Care Planning

    2-BPlease remember to write these items on every page:

    • Your name.
    • Your medical record number, which is found on your blue Kaiser insurance card.
    • Date of completion is important in case you have another Advance Health Care Directive on file, now or in the future.
    • Your medical provider name is another way we double check your identity.

  • Part 1 – My Health Care Agent – Page 3

    Part 1 – My Health Care Agent – Page 3

    3-AWhat are the qualities you should look for in agent? Learn how to choose an agent.

    3-BLearn more about what is an agent and their responsibilities

    3-CSome people don’t have anyone in mind to be their agent. Learn about Life Care Planning without an agent.

  • Part 1 – My Health Care Agent – Page 4

    Part 1 – My Health Care Agent – Page 4

    4-AAn alternate agent would be needed if your primary agent is not available. Learn more about agents

    4-BVideo: What I might consider when choosing my agent

  • Part 1 – My Health Care Agent – Page 5

    Part 1 – My Health Care Agent – Page 5

    5-AThis space may be used for any instructions related to agents and their powers. If you have a family member who has beliefs about these topics that are significantly different from yours, you may decide to exclude this person from being involved in decision-making, even informally.

    5-BLearn more about these situations.

  • Part 2 – My Values – Page 6

    Part 2 – My Values – Page 6

    6-AIn a serious medical situation, where the outcome is uncertain, your agent may look to this section for guidance. You’ll be doing your agent a favor by providing rich detail here.

    6-BFor further guidance, read your values are at the center of your life care plan.

    6-CSituations where values matter.

  • Part 3 – My Health Care Instructions – Page 7

    Part 3 – My Health Care Instructions – Page 7

    7-AShould you ever be in a similar situation, it would be valuable for your agent to know your opinion about it.

    7-BVideo: Get more details about this brain injury scenario.

    7-CVideo: Learn more accepting life sustaining treatments for a specific time period, in this scenario.

  • Part 3 – My Health Care Instructions – Page 8

    Part 3 – My Health Care Instructions – Page 8

    8-ACPR can save lives, but it’s not as effective most people think. Read a discussion about CPR.

  • Part 4 – My Hopes and Wishes – Page 9

    Part 4 – My Hopes and Wishes – Page 9

    9-ASometimes, our values inform not only what we want, but of what we don’t want. If you have some thoughts about how you would ideally like to die, please add them here.

    9-BIf you are part of a faith community, please add in details of how we may contact them.

  • Part 4 – Organ Donation, other wishes – Page 10

    Part 4 – Organ Donation, other wishes – Page 10

    10-AIf you’re interested in organ donation, please be sure your agent is aware of this. Your agent would be responsible for arranging this at the time of death.

    10-BBe aware that if you’re interested in whole body donation, this is typically arranged well in advance and requires forms and documentation.

  • Part 5 – Making this document legally valid – Page 11

    Part 5 – Making this document legally valid – Page 11

    11-ALearn more about making this document legally valid.

    11-BSpecial witness requirement is only applicable if you are currently a patient in a skilled nursing facility.

  • Part 5 – Making this document legally valid – Page 12

    Part 5 – Making this document legally valid – Page 12

    12-ALearn more about making this document legally valid.

    12-BPlease note that a witness may not also be a health care agent.

  • Part 5 – Making this document legally valid – Page 13

    Part 5 – Making this document legally valid – Page 13

    13-ALearn more about making this document legally valid.

    13-BA notary public signature is only necessary if you don’t have witnesses. It is possible to skip the notary public and make this document valid with witnesses only.

  • Part 5 – Making this document legally valid – Page 14

    Part 5 – Making this document legally valid – Page 14

    14-AIf using a notary public, you’ll want to sign in their presence.

    If you’re using witnesses, you’ll want to have your witnesses confirm that this is your signature. Or you may choose to sign in their presence.

  • Part 6 – Next Steps – page 15

    Part 6 – Next Steps – page 15

    15-ALearn more about sharing your values with your agent.

    15-BIf you have a scheduled doctor appointment, you may hand deliver a copy to your doctor. Or alternatively, you may call or visit your local Kaiser Permanente Health Education Department for questions or information on returning your Advance Health Care Directive.

    15-CIf you’d like to let your doctor know you’ve completed your Advance Health Care Directive and who you’ve chosen as your agent, you may send a secure message on kp.org using this handy email template.

    15-DRead more: With whom should you share your Life Care Plan?

    15-E?If you want to make a change to this document later, you’ll have to re-submit it. Learn more.


Download the Advance Health Care Directive

Advance Health Care Directive

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