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Advance Health Care Directive
You can download and print this form to fill out with a pen, or save it to your computer and type into it.
Download the Virginia Advance Health Care Directive now.
How to Share your Advance Health Care Directive with KP
Keep the original.
- Drop off a copy of your completed AHCD at the Medical Records Department of your Kaiser Permanente Medical Office Building.
Introduction (page 1)
1-A
Learn more about our approach to Life Care Planning
1-B
Please remember to write these items on every page:
- Your name
- Your medical record number, which is found on your blue Kaiser insurance card
Part 1: My Health Care Agent (page 2)
2-A
What are the qualities you should look for in an agent? Learn how to choose an agent.
2-B
Learn more about what an agent is, and their responsibilities.
2-C
Some people don’t have anyone in mind to be their agent. Learn about Life Care Planning without an agent.
2-D
An alternate agent would be needed if your primary agent is not available. Learn more about agents.
Part 1: My Health Care Agent (page 3)
3-A
Video: What I might consider when choosing my agent.
3-B
This space may be used for any instructions related to agents and their powers. If you have a family member who has beliefs about these topics that are significantly different from yours, you may decide to exclude this person from being involved in decision-making, even informally.
Part 1: My Health Care Agent (page 4)
4-A
In a serious medical situation, where the outcome is uncertain, your agent may look to this section for guidance. You’ll be doing your agent a favor by providing rich detail here.
4-B
For further guidance, read your values are at the center of your life care plan.
4-C
Consider some situations where values matter.
Part 3: My Health Care Instructions (page 5)
5-A
Should you ever be in a similar situation, it would be valuable for your agent to know your opinions about life sustaining treatment.
5-B
Video: Get more details about this brain injury scenario.
5-C
Video: Learn more accepting life sustaining treatments for a specific time period, in this scenario.
6-A
CPR can save lives, but it’s not as effective most people think. Read a discussion about CPR.
Part 4: My Hopes and wishes (page 7)
7-A
Sometimes, our values inform not only what we want, but of what we don’t want. If you have some thoughts about how you would ideally like to die, please add them here.
7-B
If you are part of a faith community, please add information about how we may contact them.
7-C
Be aware that if you’re interested in whole-body donation, this is typically arranged well in advance and requires forms and documentation.
7-D
If you’re interested in organ donation, please be sure your agent is aware of this. Your agent would be responsible for arranging this at the time of death.
Part 5: Making this document legally valid (page 8)
8-A
Learn more about making this document legally valid.
Your document must be signed by two adult witnesses. Please note that your appointed health care agent cannot also be your witness. At least one witness must not have the right to any financial benefit upon your death.
- Witnesses will sign on page 9
- You will sign below
Part 5: Making this documentlegally valid (page 9)
9-A
Learn more about making this document legally valid.
9-B
Please note that your health care agent cannot also be your witness.
Part 6: Next steps (page 10)
10-A
Learn more about sharing your values with your agent.
10-B
If you have a scheduled doctor appointment, you may hand deliver a copy to your doctor or you may visit Membership Services.
10-C
If you’d like to let your doctor know you’ve completed your Advance Health Care Directive, and who you’ve chosen as your agent, you may send a secure message on kp.org.
10-D
These are the people who require a copy of this document. Read more: Who needs to know about your Life Care Plan?