Form 10-0137 VA Advance Directive - Durable Power of Attorney for Hea

VA Advance Directive - Durable Power of Attorney for Health Care and Living Will (VA Form 10-0137)

VA Form 10-0137_VA Advance Directive_updated Oct 2020

VA Form 10-0137

OMB: 2900-0556

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OMB Approval Number 2900-0556
Estimated Burden Avg: 30 minutes
Expiration Date: 12/31/2020

VA ADVANCE DIRECTIVE
DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
INSTRUCTIONS
This advance directive form is an official document where you can write down your preferences for your health care. If
someday you can’t make health care decisions for yourself anymore, 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
• Describe your preferences for how you want to be treated
• Describe your preferences for medical care, mental health care, long-term care, or other types of health care
You may complete some, none, or all sections of this form. If you need more space for any part of the form, you may
attach extra pages. Be sure to initial and date every page that you attach. You also must initial the sections you
complete and sign the form. If you are unable to initial or sign the form because of a physical impairment, you can
place an “X”, thumbprint, or stamp on the form instead of your initials and signature. If a physical impairment prevents
you from doing any of these things, you can ask someone else who is with you to sign, place an “X”, thumbprint, or
stamp on the form.
When you complete this form, it's important that you also talk to a member of your health care team, family, and other
loved ones to explain what you meant when you filled out the form. A member of your health care team can help you
with this form and can answer any questions that you have.

PART I: PERSONAL INFORMATION
LAST FOUR DIGITS OF SSN:

NAME (Last, First, Middle):
STREET ADDRESS:
CITY, STATE, ZIP:
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. §17.32. It is being collected to
document your preferences for your health care in the event that you can’t speak for yourself anymore. The information
you provide may be disclosed outside the VA as permitted by law. Possible disclosures include those that are
described in the “routine uses” identified in the VA system of records 24VA10P2, Patient Medical Records-VA,
published in the Federal Register inaccordance with the Privacy Act of 1974. This is also available in the Compilation of
Privacy Act Issuances. You may choose to fill out this form or not.But without this information, VA health care providers
may not understand your preferences as well. If you don’t fill out this form, there won’t be any effect on the benefits you
are entitled to receive. The Paperwork Reduction Act of 1995 requires us to let you know that this information collection
follows the clearance requirements of section 3507 of this Act. We estimate that it will take you about 30 minutes to fill
out this form, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the information you write down. A Federal agency may not conduct or
sponsor, and a person is not required to respond to a collection of information, unless it displays a current valid OMB
control number. The OMB Control No. for this information collection is 2900-0556.

VA FORM
JUN 2020

10-0137

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
LAST FOUR DIGITS OF SSN:

NAME (Last, First, Middle):

PART II: DURABLE POWER OF ATTORNEY FOR HEALTH CARE
This section of the advance directive form is called a Durable Power of Attorney for Health Care. It lets you appoint a
specific person to make health care decisions for you in case you can’t make decisions for yourself anymore. This
person will be called your Health Care Agent.
Your Health Care Agent should be someone:
• You trust
• Who knows you well
• Who is familiar with your values and beliefs
If you get too sick to make decisions for yourself, your Health Care Agent will have the authority to make all health care
decisions for you. This includes decisions to admit and discharge you from any hospital or other health care institution.
Your Health Care Agent can also decide to start or stop any type of health care treatment. He or she can access your
personal health information, and medical records, including information about whether you have been tested for HIV or
treated for AIDS, sickle cell anemia, substance abuse or alcoholism.
NOTE: If you wish to give general permission for VA to share your medical records or health information with others,
you can complete VA Form 10-5345 (Request for and Authorization to Release Medical Records or Health
Information). You can get VA Form 10-5345 from your VA health care provider or you can get it using a computer from
this website http://www4.va.gov/vaforms/medical/pdf/vha-10-5345-fill.pdf.
A - HEALTH CARE AGENT
Place your initials in the box next to your choice. Choose only one.
Initials

I don't wish to appoint a Health Care Agent right now.
(Skip this section and go to Part III, Living Will.)

Initials

I appoint the person named below to make decisions about my health care if I can't decide for myself
anymore.
Relationship to Me:

Name (Last, First, Middle):
Street Address:
City, State, Zip:
Home Phone with Area Code:

Work Phone with Area Code:

Mobile Phone with Area Code:

B - ALTERNATE HEALTH CARE AGENT
Fill out this section if you want to appoint a second person to make health care decisions for you, in case the first
person isn’t available.
Initials

If the person named above can't or doesn't want to make decisions for me, I appoint the person named
below to act as my Health Care Agent.
Relationship to Me:

Name (Last, First, Middle):
Street Address:
City, State, Zip:
Home Phone with Area Code:

VA FORM 10-0137, JUN 2020

Work Phone with Area Code:

Mobile Phone with Area Code:

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
LAST FOUR DIGITS OF SSN:

NAME (Last, First, Middle):

PART III: LIVING WILL
This section of the advance directive form is called a Living Will. This section of it lets you write down how you want to
be treated in case you aren't able to decide for yourself anymore. Its purpose is to help others decide about your care.
A - SPECIFIC PREFERENCES ABOUT LIFE-SUSTAINING TREATMENTS
In this section, you can indicate your preferences for life-sustaining treatments in certain situations. Some examples of
life-sustaining treatments are:
• CPR (cardiopulmonary resuscitation)
• a breathing machine (mechanical ventilation)
• kidney dialysis
• a feeding tube (artificial nutrition and hydration)
Think about each situation described on the left and ask yourself, “In that situation, would I want to have life-sustaining
treatments?” Place your initials in the box that best describes your treatment preference. You may complete some, all,
or none of this section. Choose only one box for each statement.
Yes.
I would want
life-sustaining
treatments.

No.
I would not want
life-sustaining
treatments.

If I am unconscious, in a coma, or in a vegetative state and
there is little or no chance of recovery.

Initials

I'm not sure.
It would depend
on the
circumstances.

If I have permanent, severe brain damage that makes me
unable to recognize my family or friends (for example, severe
dementia).

Initials

Initials

Initials

If I have a permanent condition where other people must help
me with my daily needs (for example, eating, bathing,
toileting).

Initials

Initials

Initials

If I need to use a breathing machine and be in bed for the rest
of my life.

Initials

Initials

Initials

If I have pain or other severe symptoms that cause suffering
and can't be relieved.

Initials

Initials

Initials

If I have a condition that will make me die very soon, even
with life-sustaining treatments.
Other:

Initials

Initials

Initials

Initials

Initials

Initials

VA FORM 10-0137, JUN 2020

Initials

Initials

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
LAST FOUR DIGITS OF SSN:

NAME (Last, First, Middle):

B - MENTAL HEALTH PREFERENCES
This section is optional. You may skip this section if you do not have a serious mental health problem or if you do not
want to write down your preferences for mental health care. If you have a serious mental health condition, you might
want to write down medications that have worked for you in the past and that you would want again, or you might want
to write down the mental health facilities or hospitals that you like and those that you don’t like. If you need more space,
you may attach extra pages and use this space to refer to attached pages. Be sure to initial and date every page that
you attach.

C - ADDITIONAL PREFERENCES
This section is optional. In this space, you can write other important preferences for your health care that aren’t
described somewhere else in this document. For example, these might be social, cultural, or faith-based preferences
for care, or preferences about treatments such as feeding tubes, blood transfusions, or pain medications. If you need
more space, you may attach extra pages and use this space to refer to attached pages. Be sure to initial and date
every page that you attach.

VA FORM 10-0137, JUN 2020

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
LAST FOUR DIGITS OF SSN:

NAME (Last, First, Middle):

D - HOW STRICTLY YOU WANT YOUR PREFERENCES FOLLOWED
Place your initials in the box next to the statement that reflects how strictly you want others to follow your preferences.
Choose only one.
Initials

I want my preferences, as expressed in this Living Will, to serve as a general guide. I understand
that in some situations, the person making decisions for me may decide something different from the
preferences I express above, if they think it's in my best interests.

Initials

I want my preferences, as expressed in this Living Will, to be followed strictly, even if the person making
decisions for me thinks that this isn't in my best interests.

PART IV: SIGNATURES
A - YOUR SIGNATURE
By my signature below, I certify that this form accurately describes my preferences.
DATE

SIGNATURE (Sign in ink):

B - WITNESSES' SIGNATURES
Two people must witness your signature. Witnesses to the patient's signing of an advance directive are attesting by
their signatures only to the fact that they saw the patient or designated third party sign the VA Advance Directive form.
Neither witness may, to the witness' knowledge, be named as a beneficiary in the patient's estate, appointed as health
care agent in the advance directive, or financially responsible for the patient's care. Nor may a witness be the
designated third party who has signed the VA Advance Directive form at the direction of the patient and in the
patient's presence.

Witness #1
I personally witnessed the signing of this advance directive. I am not the designated third party who signed this VA
Advance Directive form at the direction of the patient and in the patient's presence. I am not appointed as Health Care
Agent in this advance directive. I am not financially responsible for the care of the patient making this advance
directive. To the best of my knowledge, I am not named as a beneficiary in the patient’s estate.
DATE

SIGNATURE (Sign in ink):
Name (Printed or Typed):
Street Address:
City, State, Zip:

Witness #2
I personally witnessed the signing of this advance directive. I am not the designated third party who signed this VA
Advance Directive form at the direction of the patient and in the patient's presence. I am not appointed as Health Care
Agent in this advance directive. I am not financially responsible for the care of the patient making this advance
directive. To the best of my knowledge, I am not named as a beneficiary in the patient’s estate.
SIGNATURE (Sign in ink):

DATE

Name (Printed or Typed):
Street Address:
City, State, Zip:

VA FORM 10-0137, JUN 2020

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VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
LAST FOUR DIGITS OF SSN:

NAME (Last, First, Middle):

PART V: SIGNATURE AND SEAL OF NOTARY PUBLIC (Optional)
This VA Advance Directive form is valid in VA facilities without being notarized. However, you may need to have it
notarized to be legally binding outside the VA health care setting. Space for a Notary's signature and seal is included
below.
On this

day of

, in the year of

, personally appeared before me
,

known by me to be the person who completed this document and acknowledged it as their free act and deed.
IN WITNESS WHEREOF, I have set my hand and affixed my official seal in the County of
State of
Notary Public:

,

, on the date written above.
Commission Expires:

[SEAL]

VA FORM 10-0137, JUN 2020

Page 6


File Typeapplication/pdf
File TitleVA Form 10-0137
SubjectV. A. ADVANCE DIRECTIVE ..
DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
AuthorVHA
File Modified2020-06-25
File Created2020-06-25

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