Initial Form Submission

My Medical Conditions
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Caregiver Resources
Advanced Care Planning**
Check the medical Advanced Care Planning topics that you have discussed with your health care provider:
This is a legal document (not a medical order), to appoint someone as your legal representative and provides instructions about how you wish to be treated and cared for at the end of your life. Because it is not a medical order, it is not used to help doctors, emergency medical technicians, or hospitals treat you in an emergency.
This is a legal document (not a medical order), to appoint someone as your legal representative and provides instructions about how you wish to be treated and cared for at the end of your life. Because it is not a medical order, it is not used to help doctors, emergency medical technicians, or hospitals treat you in an emergency.
This document, which varies by state, is a medical order signed by a medical professional and used for treatment. It is generally used when a person is nearing the end of life, such as with a terminal or serious illness. This is a document that your doctor can discuss with you during your Advanced Care Planning discussion. This does not name a “surrogate” or “medical proxy.” This document would be used together with the Living Will/Advanced Directive to guide your loved ones and your doctors in the event that you are unable to make your own decisions
The following documents will be attached to this Care Plan:
Plans for follow-up
Ask your medical provider to explain situations when you should call the doctor’s office, report to an emergency room, or schedule a regular follow-up appointment. What are signs and symptoms you and/or your caregiver should look out for? Make sure you write on a calendar all appointments for all caregivers to see.
Emergency Contacts
• I have thought about what medical treatment will mean for me and have discussed it with my family, caregivers, and medical providers
• This plan reflects an outline of my current medical management and plans along with those involved in my medical care
I have given a copy of my Care Plan to:
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