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Client Name (please print)Initial AssessmentDate YYY/MM/DDVisitScheduledClient Identifier TypeUnscheduledReferring health care providerHealthcare Professional Role TypeProvider identifier assigning
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Who needs chapter 166 advance directives?

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Individuals who want to make their healthcare preferences known in advance.
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People who wish to have control over their medical treatment decisions in case they become incapacitated.
03
Patients who want to appoint a healthcare proxy to make decisions on their behalf.
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Chapter 166 advance directives refer to legal documents that outline a person's healthcare wishes in case they are unable to make decisions for themselves.
Any individual who wants to specify their healthcare wishes in advance is encouraged to file chapter 166 advance directives.
To fill out chapter 166 advance directives, a person must clearly state their preferences regarding medical treatments, appoint a healthcare proxy, and sign the document in the presence of witnesses.
The purpose of chapter 166 advance directives is to ensure that an individual's healthcare preferences are honored if they become unable to communicate or make decisions.
Chapter 166 advance directives must include information about desired medical treatments, preferences for end-of-life care, appointment of a healthcare proxy, and signatures of witnesses.
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