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Advance Statement of Preferences revocation form Use this form to revoke (cancel) an Advance Statement of PreferencesHelp with this form Your treating team must help you understand this form. You

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How to fill out advance statement of preferences

01

Begin by ensuring you have the necessary form, which may vary by jurisdiction.

02

Start by providing your personal information including your full legal name, date of birth, and contact information.

03

Clearly outline your preferences for medical treatment in various scenarios, such as end-of-life care or incapacitation.

04

Consider appointing a trusted individual as your healthcare proxy to make decisions on your behalf if you are unable to do so.

05

Review and sign the document in the presence of witnesses as required by law.

Who needs advance statement of preferences?

01

Anyone who wishes to have a say in their medical care in the event they are unable to communicate their wishes.

02

Individuals with specific preferences for their end-of-life care.

03

Those who want to appoint a healthcare proxy to make medical decisions on their behalf.

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What is advance statement of preferences?

Advance statement of preferences is a document submitted by an individual to indicate their preferences for future medical treatment in the event they become incapable of making decisions.

Who is required to file advance statement of preferences?

Any individual who wishes to document their preferences for future medical treatment may file an advance statement of preferences.

How to fill out advance statement of preferences?

An advance statement of preferences can be completed by providing information about the individual's preferences for medical treatment, including specific instructions and preferences for healthcare providers to follow.

What is the purpose of advance statement of preferences?

The purpose of advance statement of preferences is to ensure that an individual's preferences for medical treatment are known and respected in the event they become incapacitated.

What information must be reported on advance statement of preferences?

Information reported on advance statement of preferences may include preferences for life-sustaining treatment, organ donation, pain management, and end-of-life care.

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