The staff of _________________ HHA is sensitive to the many concerns and decisions you face as a patient.

A federal law (The Patient Self Determination Act) requires that you are asked whether or not you have

an “advance directive” when you are admitted to a hospital, home health agency or any other healthcare

facility.

Under all state laws, every adult has the right to make certain decisions regarding his or her medical

treatment. You have the right to express your wishes related to your care through “advance directives” as

provided by state law and regulations.

“Advance directives” are written statements that specify the type of medical treatment you do or do not

want under special, serious circumstances when you may not be able to tell your physician or caregiver

how you want to be treated.

“Advance directives” is a general term for documents which outline/specify your wishes concerning life prolonging

procedures and designate the person you choose to make healthcare decisions for you if you

become unable to make these decisions yourself.

“Advance directives” may be in the form of a “Living Will” and/or may designate a third party (relative,

friend, etc.) to make decisions on your behalf using a Durable Power of Attorney for Healthcare

Decisions, or other forms allowed by your state.

_______________ HHA does not discriminate against patients in admissions to care or services offered on the

presence or absence of “advance directives” and will comply with all applicable laws.

It is important that we know if you formulate an “advance directive” while receiving care and/or services

from this HHA so that your wishes can be honored. It is also important that you provide a copy of your

“advance directives” to your physician and to the individual you have designated as your healthcare

surrogate.

If you have already formulated an “advance directive”, if you execute an “advance directive” in the future

or if you change or revoke an “advance directive”, it is important that your physician, your designated

representative, this HHA and any other organization/individual(s) involved in your care be informed.

If you indicate below that you have an “advance directive”, ________________ HHA will retain the information in

your record, will contact your attending physician for orders to comply with the terms of your

instructions, and will notify the HHA’s staff who provide care and services to you.

Likewise, if you formulate, change, or revoke an ” advance directive” at some point in the future while continuing to receive care/or services from ____________ HHA, you must notify this HHA, your physician and any other  individuals/organizations involved in your care. We include the information in your record, contact your physician for orders and notify our staff of the changes.

If you have any questions regarding “advance directives”, please contact the supervisor at ____________ HHA at _____________(Company Phone Number)