Please review the Information and Instruction page before completing this form.

Spiritual Care Advance Directive for ______________________________________

To encourage, facilitate, & authorize the partnership of care between my health care providers
& my faith community/spiritual care providers and in order to receive appropriate and timely
spiritual care, I voluntarily request and authorize my doctor and/or the staff of
________________________________________________________________________________
(Name of health care organization, health care provider(s) and/or senior living facility)
to notify my faith community or spiritual provider named below as soon as reasonably possible in the
event of one of the following as initialed by me, my next of kin, or legal representative and to share
with them the medical information (PHI) needed to determine appropriate spiritual care for me.
_____ if I am admitted to a hospital
_____ if I am sent to a hospital emergency department
_____ if I am transferred to another health care facility
_____ if I (or my family) have been informed of significant changes to my mental or physical health
_____ if I (or my family) have been informed that end of life treatment options need to be discussed
_____ if I (or my family) have been informed that it appears I am near death
_____ upon my death
_____ at my, my family, or legal representatives request
_____ Other:______________________________________________________________________
I understand I may amend or revoke the above at any time in writing. I agree to hold harmless the
facility(ies) named in this document and their staff and my doctor(s) if for any reason they fail to
initiate the notifications authorized above.
Signed______________________________________________________________Date:_______________
Or, signed on behalf of_____________________________________________________________________
By__________________________________________________________________Date:_______________
Relationship;_____________________________________________________________________________
I revoke this Advance Directive:___________________________________________Date:_______________
Witnessed by or confirmed by (Health Care Provider or Organizational Representative Signature/Title)
____________________________________________________________________Date:_______________
Faith Community Name:__________________________________________Phone #:_________________
Spiritual Care Provider(s) Name(s), Phone #s & Email Addresses:
________________________________________________________________________________________
________________________________________________________________________________________
Or, the current Spiritual Provider for the faith community named above.
Please note the faith community and its care providers are NOT to make public or disclose the information
provided by my health care providers to others without my further consent, or if I am unable, the consent of my
next of kin or legal representative.
Copy: __ for oneself __ family __ for the health care provider __ for faith community/provider
spiritualcareadvancedirective.com

2010 Rev. James H. Cunningham