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Idaho Durable Power of Attorney for Health Care and Living Will Form


Idaho Durable Power of Attorney for Health Care and Living Will Form
Idaho Durable Power of Attorney for Health Care and Living Will Form
VA FORM
DEC 2006 (RS)
10-0137
Page 1 of 6
This advance directive form is an official document where you can write down your preferences about your
medical care. If some day you become unable to make health care decisions for yourself, this advance
directive can help guide the people who will make decisions for you. You can use this form to name specific
people to make health care decisions for you and/or to describe your preferences about how you want to be
treated. When you complete this form, it is important that you also talk to your doctor, your family, or others
who may be involved in decisions about your care, to make sure they understand what you meant when you
filled out this form. A health care professional can help you with this form and can answer any questions
you might have. If more space is needed for any part of this form, you may attach additional pages. Be
sure to initial and date every page that you attach.
VA ADVANCE DIRECTIVE:
DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
OMB Approval Number 2900-0556
Estimated Burden Avg: 30 minutes
PART I: PERSONAL INFORMATION
NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
STREET ADDRESS
CITY, STATE AND ZIP CODE
HOME PHONE WITH AREA CODE
WORK PHONE WITH AREA CODE
MOBILE PHONE WITH AREA CODE
Privacy Act Information and Paperwork Reduction Act Notice
The information requested on this form is solicited under the authority of 38.C.F.R. ยง17.32. It is being collected to document your
preferences about your medical care in the event you are no longer able to express these preferences. The information you provide
may be disclosed outside the VA as permitted by law; possible disclosures include those described in the "routine uses" identified in
the VA system of records 24VA19, Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act
of 1974. This is also available in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/
privacyact/index.asp. Completion of this form is voluntary; however, without this information VA health care providers may have
less information about your preferences. Failure to furnish the information will have no adverse effect on any other benefits which
you may be entitled to receive. The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information
is estimated to average 30 minutes, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. No person will be penalized for failing to
furnish this information if it does not display a currently valid OMB control number.
Idaho Durable Power of Attorney for Health Care and Living Will Form
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