Advance Directive Patient Fact Sheet

1 What is an Advance Directive ? An Advance Directive is a legal document that speaks about your future wishes for health care when you are unable to speak for yourself. When you write an Advance Directive you are planning ahead for a variety of medical situations. What these situations have in common is that you have lost the ability to think or speak for yourself, temporarily or permanently. With an Advance Directive , when you are unconscious or unable to make decisions, you can still expect to receive care necessary for your comfort and dignity and have the right to give instructions about what types of health care you want or do not want, via the health care agent you have chosen to speak for you.

2 The authority of your health care agent will end when you regain the capacity to make your own decisions. The Vermont Ethics Network is available to help with this type of decision making issues. You can contact them at (802) 828-2909 or visit their website at Who can be your health care agent? Your health care agent must be someone over the age of 18 and should be someone you know and trust and can make decisions for you based upon your wishes and values. You cannot appoint your Primary care Provider or other health care clinician to be your health care agent.

3 Why is it important? No matter how young or old, how healthy or sick you are, you could have an accident or unexpected medical condition and suddenly be unable to speak for yourself. At these times, your health care agent, guided by your expressed wishes, can speak for you. Without an Advance Directive , those making decisions for you may not know what your wishes are. Worse still, your family and friends could argue over the life-sustaining care you should get. The wishes and values you express in your Advance Directive will help them help you.

4 Where is my Advance Directive stored? As your Primary care Provider, we will save your Advance Directive in your medical files here at CHCB, as well as University of Vermont Medical Center and the Vermont Advance Directive Registry. In this way, your Advance Directive may be accessed in a timely manner when it is needed. Of course, you can give copies to your health care agent and family and friends as you see fit. FOR MORE INFORMATION, CALL CHCB S SOCIAL WORK LINE AT (802) 860-4323. Advance Directive Patient Fact Sheet Vermont Advance Directive Registry REGISTRATION AGREEMENT VERMONT DEPARTMENT OF health SOURCE CODE: 53101301 Registry Use Only Received: Confirmed: 1.

5 Read the Registration Policy, and complete this Registration Agreement. Please type or print clearly. Be sure to sign and date the form. 2. Attach either a copy of your Advance Directive , or optionally, an Advance Directive Locator form which indicates only the physical location of your Advance Directive so that it can be retrieved. 3. Registrations MUST include a completed and signed Registration Agreement form, and a copy of your Advance Directive document. 4. MAIL to: Vermont Advance Directive Registry (VADR) PO Box 2789 Westfield, NJ 07091-2789 5.

6 OR FAX to: 908- 654-1919 For additional information visit: or call 1-888-548-9455 Registrant Name: First Middle Last Suffix Gender: Male_ Female Date of Birth (MM/DD/YYYY): Primary Mailing Address: Apt # City/Town: State: Zip: Phone: Home Work Other Secondary Mailing Address: Apt # City/Town: State: Zip: Emergency Contacts Primary: Name Relationship to Registrant: Mailing Address: City/Town: State: Zip: Phone: Home Work/Other: Secondary: Name Relationship to Registrant: Phone: Home Work/Other: I, (print name) request that my Advance Directive be registered in the Vermont Advance Directive Registry, and authorize its access as allowed by Vermont law.

7 By signing below, I acknowledge and affirm that: the information provided is accurate; I have read, understand, and agree to the terms of the Registry Registration Policy; I will safeguard my registrant identification number and wallet card from unauthorized access; and I will immediately notify the Registry in writing of changes to my registration information or Advance Directive . I execute this agreement voluntarily and without coercion, duress, or undue influence by any party.

8 I understand that anyone who has access to my wallet card can use it to gain access to my documents and personal information. This authorization remains in effect until I revoke it. Signature of Registrant: Date: VERMONT Advance Directive REGISTRY REGISTRATION POLICY An Advance Directive is a legal document that conveys a person s wishes regarding their health care treatment and end of life choices should they become incapacitated or otherwise unable to make those decisions.

9 The Vermont Advance Directive Registry is a database that allows people to electronically store a copy of their Advance Directive document in a secure database. That database may be accessed when needed by authorized health care providers, health care facilities, residential care facilities, funeral directors, and crematory operators. For more information, visit: 1. To register an Advance Directive , the registrant must complete and send the Registration Agreement form along with a copy of the Advance Directive to: The Vermont Advance Directive Registry PO Box 2789 Westfield, New Jersey 07091-2789 2.

10 Upon receipt of the Registration Agreement and attachments, the Registry will scan the Advance Directive and store it in the database along with registrant identifying information from the Registration Agreement. The Registry will send a confirmation letter to the registrant along with a registration number, instructions for using the registration number to access documents at the Registry website, a wallet card, and stickers to affix to a driver s license or insurance card. The registration is not effective until receipt of the confirmation letter and registration materials is made by registrant.