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LIVING WILL (1)

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Print Form Utah Advance Health Care Directive (Pursuant to Utah Code Section 75-2a-117, effective 2009 )* Part I: Allows you to name another person to make health care decisions for you when you cannot make decisions or speak for yourself. Part II: Allows you to record your wishes about health care in writing. Part III: Tells you how to revoke or change this directive. Part IV: Makes your directive legal. My Personal Information Name: ______________________________________________________________________________ Street Address: _______________________________________________________________________ City, State, Zip Code: _________________________________________________________________ Telephone: (_______) _____________________ Cell Phone: (_______) _____________________ Birth Date: ____________________________ Part I: My Agent (Health Care Power of Attorney) A. No Agent If you do not want to name an agent, initial the box below, then go to Part II; do not name an agent in B or C below. No one can force you to name an agent. I do not want to choose an agent. B. My Agent Agent’s Name: _______________________________________________________________________ Street Address: ____ ...
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