‘aed nS {YA Department of Veterans Affairs ‘VA ADVANCE DIRECTIVE DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL This advance crecve form is an oficial ocument where you can write down your preferences for your heath care, i somaday you cant make health care decisions for yourself anymore, this advance directive can help guide the people who wil make decisions for you. ‘You can use this frm to: ‘Name specific people to make healthcare decisions fr you 1 Describe your preferences forhow you want tobe treated ‘+ Describe yourpreferences for medical care, mental heth cae, long-term care, or other types of heath \When you complete this form, i's important that you aso tak to your doctor, family, and other loved ones who may help to decide about your care. You shauld explain what you meant when you filed out the form, ‘Ahealth care professional can help you with this form and can answer any questions that you have. f you reed more space fr any part ofthe form, you may attach extra pages. Be sure to ital and date every page that you attach. PART |: PERSONAL INFORMATION NAME (Lat Fist Maier LAST FOUR DIGITS OF SSN STREET ADDRESS: lciry, STATE, ZIP: [HOME PHONE WITHAREA CODE: | WORK PHONE WITH AREA CODE: | MOSILE PHONE WITH AREA CODE Privacy Act Information and Paperwork Reduction Act Notice “The omaton requested on ths forms sokted under he authrty of 38 CER. 17.32. being colette docuent Your prelerences for your heath caren the overt hat you eat speak fr yours anymore. The information you provide ‘hay be cecoued ute the VA ae pormited by aw, Poel hasosres nc oe tat be decribed the Totne {her sate nthe Va sytem of records 24VA19, Paes adal Reser VA. pied ite Feral Regie h ‘ecordance wth te Friaoy ha of 174, Th also susie the Compton Privacy Act nsusnces ‘tine. ansacnst goipevacacindexink You may ctoove ffi out Dl or er ot Bt wif tis nformaton VA eth care providers ray no undertan your peetorenos as wel ou dort cts om, there wert be any elect an {he boot you are etd fo Yesewe. The Paperwak Reduclon Ac 1086 requ us te you kaw hat Os ‘onranoncoloeas tows tne aearance reqaromes af econ 0 ef is Ace We etnso ar wi no Yeu SSCut ‘0 minutes tout ts frm, ncn the tne fr evewnginstucton, searching exisng data sources, gang ard ‘Tananing he dea eecoa and completing and eiowing ihe iteration yeu wre down. AFedo‘al agoy may net ‘Conductor sponsor, ad person rat eafea to respond fo calecbon of lferraten,uness Xepaye 8 Cet vad ‘Se cnet number, ne OM Control No fori inrmatin cotarton 29000566, “ite 10-0137 Page 1017\VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL NAME (Last Fist ie) AST FOUR DIGITS OF 88h PART It DURABLE POWER OF ATTORNEY FOR HEALTH CARE. “This section ofthe advance directive form is called a Durable Power of Attorney for Health Car. It ets you _appoint a specfic person tomake heath care decisions for you in case you cart make decisions for ‘Yurso anymore. This person willbe called your Health Care Agent. ‘Your Heath Care Agent should be someone: * You rust Who knows you well + ho i familar wih your values and beliefs It you get too sick to make deialons fr yourself, your Health Care Agent wil have the authority to make all healthcare decisions for you. Ths includes decisions to admit and discharge you from any hospital or other healthcare inettution. Your Heath Care Agent can also decide to start or stop any typeof heath care treatment He or she can access your personal health information, inuding your medical records NOTE: Information about wrether you have been teste for HIV or treated fr AIDS, sickle cel anemia, ‘Substance abuse or alcoholem wil onl be shared with your Heath Care Agent under very limited ‘Sroumstances. if you wish give general permission for VA to share this information with your Health Care ‘Agent you wil need to give special wen consent by completing VA Form 10-5846. You can get VA Form $10:5249 from your VA healh care provider or you can get itusing a computer fom this website atoll rmlmedicalpdlvha 7 ‘A HEALTH CARE AGENT Pace your ina in the bo» next to your choice. Choose ony one ‘a= || dont wish to appolat a Heath Care Agent right now. (Skip this section and goto Part ll, Living Wil) "HHT appoint the person named below to make decisions about my heath care fl cant decide for myself anymore, Tame (Las, Fst ie} Reatonstp owe ‘Sreet Fares iy, Sie, Zi ome Prone wit Area Code ‘rk Pane wth Area Code Tob Pane wih Area Code: = wee 10-0137 Page20t7\VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL NAME (Last Fit, Mile) [AST FOUR DIGITS OF SSN "ALTERNATE HEALTH CARE AGENT Fil out this section if you want to appoint a second person to make healthcare decisions for you, in case the frst person isnt avaiable. the person named above can't or dosant want to make decisions fr me, | appoint the pareen ‘named below to act as my Health Care Agent. Tame (Las Fi, wie ataioratip to We ‘Breet haar iy, Sie, ame Phone wi Area Cae ‘Wk Brave wi Area Code ‘able Prone wh Area Code PART Ir LIVING WILL, ris section of the advance directive frm is called a Living Wl. This section of lets yeu wite down how you want o be treated in ease you aren abl to decide for yourself anymore. Its purpose i to help others [decide about your care. ’A SPECIFIC PREFERENCES ABOUT LIFE-SUSTAINING TREATMENTS in his section, you can indicate your preferences fr ife-sustaining treatments in certain situations. Some examples offfe-sustaning treatments are: + CPR (cardiopulmonary resuscaton) {breathing machine (mechanical venation) kidney citys a feadhg tube (artical nuttin and hydration) think about each situation deserined onthe lft and ask yourself, “in that station, would | want to have ifesustaining treatments?” Place your intial inthe box thal best describes your treatment preference. You may complete some, all, or none of this section. Choose only one box for each statement. Yes. | Tanataure § Ne, Iwouldwart | Weald dapene | | woud net want Mesustaning | “ontwe | Mesustaning Ireatmens, | crcumstances. | _eaimets Iam uncosscious, ina coma, or ina vegetative ‘state and the I ile or no chance of recovery fT have permanent, severe brain damage that vo | — rm ‘makes ma unable o recognize my family or tends Wor example, severe dementia) ‘ise 10-0137 Page 087TN \VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL NA (as Ft Me) AST FOUR DISTS OF BSN ve Tansee] Ne, wouliiant | ‘woud depend | 1 woud nx ant causing | “onthe | ‘Wesstanng eaten” | cheomstances, | toaterts ‘Fi havea permanent condtion where cher people | ase me ‘wn trust help me win my diy nee (or exampe, eating, bathing, altng) ii needo use a bresthing machine and be inbed | ee “oe ~~ forthe est fyi iTiave pan or oer severe symptoms that cause | “ — suring and cant be reeved Ihave a condo hat will make mec very soon, |" ve “ ven wth He sustain weatments oie co = ve 'B- MENTAL HEALTH PREFERENCES. Fis sedi is optional You may skp this secon fyou do not have a serious mental heah problem or fyou do not wart to wite down your preferences for mental health care. If you have a serous mental heath Sonaion, you right wat owe down medications that have worked fr you in the past and that you would want agai or you might want to write dow the mental heath faites or hospitals that you tke and those hat you don't ike. If yOu need more space, you may attach extra pages and use this spece to refer to attached pages. Be sue to intial and date every page that you attach, “itsw 10-0137 Page 4 of7\VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL. ANE (Last Fst Moe) LAST FOUR DIGITS OF SN ‘G- ADDITIONAL PREFERENCES This section fs optional inthis pace, you can write other Important preferences for your health care that aren’ described somewhere eee inthis document. For example, these might be social, cultural, or faith-based preferences fr care, of preferences about treatments such 9 feeding tubes, blood transfusions, or pain medications. f you need mote space, you may attach extra pages and use ths space to refer to attached pages. Be sue to nial and date every page that you attach, 'D- HOW STRICTLY YOU WANT YOUR PREFERENCES FOLLOWED Pace your ial inthe box next to the statement that reflects how srcly you want others to flow your preferences, Choasncnty on | want my preferences, as expressed inthis Living Wil, to serve as a general guide. | understand that in some stuations, the person making decisions for me may decide something differen rom the preferences | express above, if they think I's n my best interests. | want my preferences, a expressed in his Living Wl, tobe followed sty, even Ifthe person ‘making decisis fr me thinks that his isin my best interests. ‘kon 10-0137 Page Sof7\VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL THAME (Last Fst, MiGae) LAST FOUR DIGITS OF 8K PART Wr SIGNATURES "A= YOUR SIGNATURE By my signature below, | erty tha this form accurately describes my preferences. ‘SIGNATURE DATE 1 WITNESSES" SIGNATURES: Two people must witness your signature. VA employees may be witnesses they are members of * The Chaplain Service The Social Work Service + Noncinicl employees (e., Medical Adminstration Service, Voluntary Serie, or Environmental Management Service) Lothar employes of you VA fey may ot sign ae wlinesres to sour advance directive unless yen our fami. Witness #1 personaly wiinessed the sgning ofthis advance directive. | am not appointed as Health Care Agent in his advance arectve. | am not inancialy responsible forthe care ofthe pereon meking ths advance directive To the best of my knowledge, | am not named inthe person's wil ‘SIGNATURE! DATE: Name nied or Typed ‘Siesta iy, Sate Witness #2 personaly witnessed the spring of is advance directive. | am nol appointed as Heath Gare Agent nts advance directive. | am not inancialy responsible forthe care ofthe person making this advance directive. [To the best of my knowledge, | am not named inthe person's wil SIGNATURE: DATE: Name (ed or Type ‘Sroet hares Civ. Sie “New 10-0137 Pages ot7\VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL. NAME (Lat, Ft, Mica) LAST FOUR DIGITS OF SSNs PART V: SIGNATURE AND SEAL OF NOTARY PUBLIC (Optional) Frhis VA Advance Directhe form is vad in VA facies without being notarized. However, you may need to have # notarized to be legally binding outside the VA health care settng, Space fora Nolan’ signature and seals included below. On this day of sin the year of. . personally appeared before me . known by me to be the person who completed this document and acknowledged it as thelr free act Jand deed. IN WITNESS WHEREOF, | have set my hand and affixed my offcial seal in the County of State of + on the date writen above. Notary Public__—_—_____ Commission Expires (Seay) ‘iow 10-0137 Faye 7of7