Last updated on Feb 20, 2026
US-Q1026 free printable template
Show details
Living Will Advanced Health Care Directive Questionnaire Your name Home phone Birth date Address Work phone Cell phone Do you wish the living will to take effect now or only if you are disabled or incapacitated Duration of living will to be Do you wish to appoint a conservator Yes No If yes please provide name address and phone number Do you wish to be kept on artificial life support Yes Which of the following do you consider to be a terminal condition An incurable and irreversible condition...that requires life support A permanent coma A persistent vegetative state Do you want food water administered if you are in terminal condition Yes Do you want any limitations on pain medication Yes If yes describe Do you wish to donate organs Yes If yes for what purpose s Transplant Education Research Therapy Who would you like to make the donation to A particular physician A medical facility A specific donor Any person or entity Alternate physician Alternate donor TISSUE Eyes Bone and...connective tissue Skin Heart Other ORGAN Kidney s Liver Lung s Pancreas Will you appoint an individual to make health care decisions for you Yes If yes Name of Health Care Representative Relationship Age Address of Representative Phone Number of Representative Will the Representative benefit in any way by your death beneficiary in your will insurance policy etc. Yes If yes please describe person above is unable unavailable or unwilling to act Yes Name of alternate Health Care Representative...Address of alternate Representative Will the alternate Representative benefit in any way by your death beneficiary in your will insurance policy etc. Yes Physician s name Phone number Will personal representative be able to authorize the disposal of body remains Yes If there are any health care decisions you do not wish the Representative to make please describe Yes location rather than in a hospital Yes Do you wish to express desires regarding funeral arrangements Yes please describe If you...have any further health care instructions please describe if yes.
We are not affiliated with any brand or entity on this form
Fill out
Complete the form online in a simple drag-and-drop editor.
eSign
Add your legally binding signature or send the form for signing.
Share
Share the form via a link, letting anyone fill it out from any device.
Export
Download, print, email, or move the form to your cloud storage.
Why choose pdfFiller for your legal forms?
All-in-one solution
pdfFiller offers a PDF editor, eSignatures, file sharing, collaboration tools, and secure storage—all in one place.
Easy to use
pdfFiller is simple, cloud-based, has a mobile app, and requires no downloads or a steep learning curve.
Secure and compliant
With encryption, user authentication, and certifications like HIPAA, SOC 2 Type II, and PCI DSS, pdfFiller keeps sensitive legal forms secure.
What is US-Q1026
US-Q1026 is a form used for reporting and documenting specific information required by regulatory authorities.
pdfFiller scores top ratings on review platforms
NOT ALWAYS EASY TO N=KNOW WHAT TO DO NEXT
No issues once I contacted the support department who answered my questions. I understand that you are in business to make money on a service. I just felt it was costly for a piece of paper or two that would cost me 10. Cents at a FedEx or Office Max type business.
I love the ease of typing on the PDF, I'm still learning how to send it to others with fill in blanks. But I like it. Pricey for the redaction ability but I suppose better than Adobe
it is not as smooth as i would liek and the editing capabilites are not strong.
great site.. many things can be done that are otherwise impossible.
Great
Needs better control on the circle option
Who needs US-Q1026?
Explore how professionals across industries use pdfFiller.
US-Q1026 is needed by:
-
Businesses subject to regulatory reporting requirements
-
Compliance officers in organizations
-
Accountants and financial analysts
-
Legal professionals handling compliance matters
Ultimate Guide to the US-Q1026 Form on pdfFiller
Understanding the US-Q1026 form
The US-Q1026 form serves as a crucial document that outlines individual health care directives. It is designed to ensure that your health care preferences are documented and respected, particularly in situations where you may not be able to communicate those preferences yourself.
-
The form specifies your choices about medical treatment and defines how you wish to be cared for in critical conditions.
-
Having a documented directive ensures your wishes are followed by health care providers and your family.
-
This form is vital for upholding your rights as a patient, allowing you to control your health care even when you can't express it.
What are the key components of the US-Q1026 form?
-
This section records essential details such as your name, address, and contact information.
-
You must state clearly your wishes regarding life support measures and organ donation.
-
This allows you to appoint individuals to make health care decisions on your behalf if you are unable to do so.
How do you fill out the US-Q1026 form: Step-by-Step?
Filling out the US-Q1026 form involves several organized steps to ensure accuracy and clarity in your directives.
-
Collect your identification information and health care preferences in advance.
-
Carefully fill out your name, contact details, and preferences regarding life support, organ donation, and health care representatives.
-
If you wish, include the name of a conservator to make decisions on your behalf.
-
Ensure all parts are completed correctly before submission.
How to edit and manage your US-Q1026 form on pdfFiller?
pdfFiller offers flexible features that allow you to manage your US-Q1026 form effectively. Once completed, you can access it anytime to make updates or changes.
-
Log into your pdfFiller account to retrieve your form for further editing.
-
You can quickly eSign your document for validation, ensuring it's legally recognized.
-
Share your form securely with family members or healthcare providers for input and support.
What are common mistakes to avoid when completing the US-Q1026 form?
-
Always indicate how long you want your living will to remain effective to avoid confusion.
-
Make sure that your wishes regarding treatment are unambiguous and explicitly stated.
-
Regularly review and update your appointed health care representatives to keep them relevant.
What are the legal considerations for the US-Q1026 form?
Each state may have different regulations regarding living wills, so it's crucial to understand your local laws that govern the US-Q1026 form.
-
Investigate your state’s regulations that dictate how living wills are to be constructed and validated.
-
Consult legal advice on whether your form needs to be witnessed or notarized for legality.
-
Familiarize yourself with the process to follow in case disputes arise regarding your health care directives.
How to fill out the US-Q1026
-
1.Open the US-Q1026 form in pdfFiller.
-
2.Begin by entering the date at the top of the form in the designated field.
-
3.Fill out your organization’s name and contact information in the specified section.
-
4.Provide the relevant details required in each subsection of the form, ensuring all information is accurate.
-
5.Attach any supplementary documents that may be needed as attachments or supporting files, if applicable.
-
6.Review all entries for completeness and accuracy before submission.
-
7.Once verified, finalize the form and submit it using the provided submission method or save it for your records.
Related Forms
Related Catalogs
If you believe that this page should be taken down, please follow our DMCA take down process
here
.
This form may include fields for payment information. Data entered in these fields is not covered by PCI DSS compliance.