Advance Health Care Directive

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Download Oregon’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 Oregon’s
Advance Health Care Directive

These pages provide tips and instruction for each page.

Oregon Advance Health Care Directive - cover

Advance Health Care Directive

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 the Oregon 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 your local Membership Services office or mail to:
    Kaiser Permanente Process Center
    Medical Records Department – Advance Directive
    10220 SE Sunnyside Road, Clackamas, OR 97015-9734

Oregon 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.
  • 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.

Oregon Advance Health Care Directive - page 2

Part 1 – My Values – Page 2

2-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.

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

2-CSituations where values matter.

Oregon Advance Health Care Directive - page 3

Part 2 – My Health Care Instructions – Page 3

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

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

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

Oregon Advance Health Care Directive - page 4

Part 2 – My Health Care Instructions – Page 4

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

Oregon Advance Health Care Directive - page 5

Part 3 – My Hopes and Wishes – Page 5

5-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.

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

Oregon Advance Health Care Directive - page 6

Part 3 – Organ Donation, other wishes – Page 6

6-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.

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

Oregon Advance Health Care Directive - page 7

Part 4 – Making this document legally valid – Page 7

7-AThis is the legally required part of the advance directive form in the State of Oregon.

Oregon Advance Health Care Directive - page 8

Part 4 – Making this document legally valid – Page 8

8-AFill in your name, date of birth your current address and initial one of the options.

KP recommends that you initial My Entire Life. If you change your mind about any part of this form, you are free to submit a new form. KP will use the most recent form you submit.

8-BAppointment of health care representative (agent)
Write the name, address and telephone number of your representative, and an alternate (back-up) person in case your representative can’t be reached.

Choose someone who you have talked with about your wishes and you feel comfortable they would represent your wishes for you.

8-CLimits
Write any specific instructions here. Some people write if there is someone specific that they DO NOT want to make decisions on their behalf.

It is ok to leave this blank.

8-DInitial the bottom of page 8.

When you initial “I have executed…” this means that you are completing this form.

Oregon Advance Health Care Directive - page 9

Part 4 – Making this document legally valid – Page 9

9-ALife Support
Initial if you give permission for your agent to make decisions about life support.

If you want your agent to ONLY follow what you have written, leave this blank

9-BTube Feeding
Initial if you give permission for your agent to make decisions about tube feeding.

If you want your agent to ONLY follow what you have written, leave this blank.

9-CDate on the top line

Sign on the bottom line

Signing and dating here confirms you are appointing a representative (agent)

9-DHealth care instructions

You may either give specific instructions by filling out items 1 to 4 OR fill out number 5 to give general instructions.

9-EInitial one option under each question (1-4). You may choose to have all treatment available (first option),advice from the physician for your agent (second option), or chose to have no treatment. You will always be kept comfortable.

If you chose “as physician recommends” your agent and your physician will have a discussion about what could help you the most at that time.

Oregon Advance Health Care Directive - page 10

Part 4 – Making this document legally valid – Page 10

Initial one option under each question (10-A, 10-B, 10-C). You may choose to have all treatment available (first option),advice from the physician for your agent (second option), or chose to have no treatment. You will always be kept comfortable.

If you chose “as physician recommends” your agent and your physician will have a discussion about what could help you the most at that time.

Oregon Advance Health Care Directive - page 11

Part 4 – Making this document legally valid – Page 11

11-AGeneral Instructions

Initial this option if you want no life support at all if you couldn’t speak for yourself and any of C1-4 were true (you were close to death, permanently unconscious, had an illness that would not get better or were suffering a lot).

You may chose to leave 1-4 blank and only initial this one if it represents your decisions of to be allowed to die naturally if any of those situations were true.

You may also chose to initial that you do NOT want life support on 1-4 AND fill out 5 as well, but it is not required.

11-BAdditional conditions or instructions

Write specific instructions here if you have any.

For example- “no blood products” or “please play music for me” or “I only want life support for a maximum of one week” etc.

11-COther documents

Most people will leave this section blank.

If you are positive you have done a form before, please initial #2.

If you aren’t sure, but you want to be extra safe, it is fine to initial number 2. Otherwise, leave blank.

11-DDate on the top line

Sign on the bottom line

Signing and dating here confirms you are expressing your wishes for treatment in the above situations.

Oregon Advance Health Care Directive - page 12

Part 4 – Making this document legally valid – Page 12

12-ADeclaration of witnesses

Two witnesses MUST sign, date and print their names.

One of these two cannot be related

Think of people who know who you are – a neighbor, a friend, an acquaintance. KP employees cannot witness your forms.

12-BAcceptance by health care representative

Your agent and back up sign and date here.

By signing and dating, your agent acknowledges that they understand your wishes and will represent them for you.

Be sure to Mail KP a copy!!

Medical records will scan it in to your chart to make sure everyone at KP can see it.

Oregon Advance Health Care Directive - page 13

Part 5 – Next Steps – page 13

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 your Health Engagement and Wellness Department for questions or information on returning you 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?