CONCEPT #98 OF 100 · Medical, Dental & Clinical Practices · LAYOUT: pleading_caption
Advance Healthcare Directive, Living Will & HIPAA Medical Surrogate Designation
Standard / Reference: Uniform Health-Care Decisions Act (UHCDA) · 45 C.F.R. § 164.508 (HIPAA) · 42 U.S.C. § 1395cc PSDA
Why professionals use this template: 38,000/mo search demand: individuals and hospital systems needing clear, plain-language Advance Healthcare Directives combining Surrogate Appointment, End-of-Life Living Will choices, Organ Donation, and immediate HIPAA release.
144-DPI VECTOR PREVIEW · PAGE 1 OF 1
ACROFORM READY
Included Financial Metrics & Line-Item Schedule
Target Roles: Estate Planners, Hospital Palliative Care Teams, Patient Advocates & Primary Care Clinics · Search Keywords: advance healthcare directive and living will form pdf, medical power of attorney healthcare proxy form, uniform health care decisions act declaration, hipaa 45 cfr 164.508 medical release
PRIMARY HEALTH SURROGATE
Christopher Vance (Son)
ALTERNATE SURROGATE
Claire Vance-Miller (Daughter)
TERMINAL / PVS DIRECTIVE
Comfort Care Only (Withhold Life Support)
HIPAA 45 CFR § 164.508
Immediate Full Medical Release
| CODE | DESCRIPTION & TECHNICAL SPECIFICATION | BASIS / QTY | AMOUNT / DELTA |
|---|---|---|---|
| PRT-01 | Part I — Designation of Primary & Successor Healthcare Surrogate Agents (Full Clinical Decision Authority) | UHCDA § 2(b) | DESIGNATED |
| PRT-02 | Part II — Living Will Quality-of-Life Declaration (Terminal Condition / Irreversible Coma Elections) | Initialed [ERV] | COMFORT CARE |
| PRT-03 | Part III — Artificial Nutrition & Hydration Directive (Withhold Long-Term Surgical Feeding Tube in PVS) | Initialed [ERV] | ELECTED |
| PRT-04 | Part IV — Immediate HIPAA Protected Health Information Release & Uniform Anatomical Gift Election | 45 CFR § 164.508 | FULL AUTHORIZATION |
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