Advance Health Care Directive

Ready to complete the form?

Download Maryland’s Advance Health Care Directive

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.

Page-by-page Guide to Maryland’s
Advance Health Care Directive

These pages provide tips and instruction for each page.

Maryland Advance Health Care Directive cover

Advance Health Care Directive

You can download and print form to fill out with a pen, or save it to your computer and type into it.

Download the Maryland Advance Health Care Directive now.

Share your Advance Health Care Directive with KP:

  • Keep the original.
  • Drop off a copy of your completed AHCD at the Medical Records Department of your Kaiser Permanente Medical Office Building.

Maryland Advance Health Care Directive page 1

Introduction – Page 1

1-ALearn more about our approach to Life Care Planning

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

  • Your name.
  • Your medical record number, which is found on your blue Kaiser insurance card.

Maryland Advance Health Care Directive page 2

Part 1 – My Health Care Agent – Page 2

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

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

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

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

Maryland Advance Health Care Directive page 3

Part 1 – My Health Care Agent – Page 3

3-AVideo: What I might consider when choosing my agent

3-BThis 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.

Maryland Advance Health Care Directive page 4

Part 1 – My Values – Page 4

4-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.

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

4-CSituations where values matter.

Maryland Advance Health Care Directive page 5

Part 3 – My Health Care Instructions – Page 5

5-AShould you ever be in a similar situation, it would be valuable for your agent to know your opinions about life sustaining treatment.

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

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

Maryland Advance Health Care Directive page 6

Part 3 – My Health Care Instructions – Page 6

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

Maryland Advance Health Care Directive page 7

Part 4 – My Hopes and Wishes – Page 7

7-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.

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

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

7-DIf 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.

Maryland Advance Health Care Directive page 8

Part 5 – Making this document legally valid – Page 8

8-ALearn more about making this document legally valid.

8-BPlease note that a witness may not be your appointed health care agent. In addition remember: It must be signed by two adult witnesses: at least one witness cannot have the right to any financial benefit upon your death.

  • Witnesses will sign on page 9
  • You will sign below.

Maryland Advance Health Care Directive page 9

Part 5 – Making this document legally valid – Page 9

9-ALearn more about making this document legally valid.

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

Maryland Advance Health Care Directive page 10

Part 6 – Next Steps – page 10

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

10-BIf you have a scheduled appointment, you may hand deliver a copy to your doctor or you may visit Membership Services.

10-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.

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