- What is Life Care Planning
- Consider your values
- Choose your agent
- Tell everyone
Ready to complete the form? These pages provide tips and instruction for each page. You can download and print form to fill out with a pen, or save it to your computer and type into it. 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.
At this time, we only accept the Advance Health Care Directive on paper.
You can download and print form to fill out with a pen, or save it to your computer and type into it.
Download Advance Health Care Directive now.
1-ALearn more about our approach to Life Care Planning
1-BPlease remember to write these items on every page:
3-AAn alternate agent would be needed if your primary agent is not available. Learn more about agents
3-BVideo: What I might consider when choosing my agent
4-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-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.
5-BFor further guidance, read your values are at the center of your life care plan.
6-AShould you ever be in a similar situation, it would be valuable for your agent to know your opinion about it.
6-BVideo: Get more details about this brain injury scenario.
6-CVideo: Learn more accepting life sustaining treatments for a specific time period, in this scenario.
7-ACPR can save lives, but it’s not as effective most people think. Read a discussion about CPR.
8-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.
8-BIf you are part of a faith community, please add in details of how we may contact them.
9-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.
9-BBe aware that if you’re interested in whole body donation, this is typically arranged well in advance and requires forms and documentation.
10-ALearn more about making this document legally valid.
10-BSpecial witness requirement is only applicable if you are currently a patient in a skilled nursing facility.
11-ALearn more about making this document legally valid.
11-BPlease note that a witness may not also be a health care agent.
12-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. .
12-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.
13-ALearn more about sharing your values with your agent.
13-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.
13-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.
13-DRead more: With whom should you share your Life Care Plan?
Ready to complete your Advance Health Care Directive based on your Life Care Plan?Start now