Advance directive acknowledgement form 2026

1. Click ‘Get Form’ to open the advance directive acknowledgement form in the editor.
2. Begin by entering your name, address, social security number, and date of birth in the designated fields at the top of the form.
3. In section 1, indicate whether you have received written information regarding your rights concerning medical care by selecting 'YES' or 'NO'.
4. For section 2, specify if you have formulated an advance directive by checking the appropriate boxes for 'Declaration' and/or 'Durable Power of Attorney for Health Care Decisions'.
5. If you marked 'YES', confirm whether you have provided a copy of your advance directive to the hospital. Check the box if a copy is provided.
6. Use the comments section to note any follow-up efforts needed if you cannot provide your advance directives upon admission.
7. Finally, sign and date the form at the bottom. If applicable, have a family member or hospital representative sign as well.

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