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Utah _____________________ Phone: _______________________________________ 2 ___________ Phone: _______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: _________________ a patient at the time of signing this directive. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ___________________________er any will or codicil of declarant; that we are not directly financially responsible for declarant's medical care; and that we are not agents of any health care facility in which the declarant may bethe declarant; that we are not related to the declarant by blood or marriage nor are we entitled to any portion of declarant's estate according to the laws of intestate succession of this state or und are acquainted with the declarant and believe him to be of sound mind; that the declarant's desires are as expressed above; that neither of us is a person who signed the above directive on behalf of City, County, and State of Residence We witnesses certify that each of us is 18 years of age or older and each personally witnessed the declarant sign or direct the signing of this directive; that we this directive. _____________________________________________________________________________ (Declarant's Signature) 1 _____________________________________________________________________________the above written directive that life-sustaining procedures be withheld or withdrawn. 6. I understand the full import of this directive and declare that I am emotionally and mentally competent to make__________________ 5. I reserve the right to give current medical directions to physicians and other providers of medical services so long as I am able, even though these directions may conflict with __ _______________________________________________________________________ _______________________________________________________________________ _____________________________________________________stration of medication or the performance of any medical procedure which is intended to provide comfort care or to alleviate pain: _____________________________________________________________________and that the term "life-sustaining procedure" includes artificial nutrition and hydration and any other procedures that I specify below to be considered life-sustaining but does not include the adminiences from this refusal which shall remain in effect notwithstanding my future inability to give current medical directions to treating physicians and other providers of medical services. 4. I understithdrawn and my death be permitted to occur naturally. 3. I expressly intend this directive to be a final expression of my legal right to refuse medical or surgical treatment and to accept the consequn of life-sustaining procedures would serve only to unnaturally prolong the moment of my death and to unnaturally postpone or prolong the dying process, I direct that these procedures be withheld or wllness, which is certified in writing to be a terminal condition or persistent vegetative state by two physicians who have personally examined me, and in the opinion of those physicians the applicatiore that my life not be artificially prolonged by life-sustaining procedures except as I may otherwise provide in this directive. 2. I declare that if at any time I should have an injury, disease, or iade this _______________ day of ___________________, 20_____ 1. I, __________________________________________________________________, being of sound mind, willfully and voluntarily make known my desiese forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Directive To Physicians And Providers Of Medical Services (Pursuant to Section 75-2-1104, UCA) This directive is m is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of th. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to stateimilar to the form approved by prior Utah law: (see form below) [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for anyagent of any health care facility in which the declarant is a patient at the time the directive is executed. (4) The directive shall be in substantially the following form or in a form substantially s declarant according to the laws of intestate succession of this state or under any will or codicil of the declarant; (d) directly financially responsible for the declarant's medical care; or (e) any he person who signed the directive on behalf of the declarant; (b) related to the declarant by blood or marriage; Information & Instructions ­ Page 3 (c) entitled to any portion of the estate of thedeclarant's presence and by the declarant's expressed direction; (c) dated; and (d) signed in the presence of two or more witnesses 18 years of age or older. (3) Neither of the witnesses may be: (a) trt. The directive is binding upon attending physicians and all other providers of medical services. (2) The directive shall be: (a) in writing; (b) signed by the declarant or by another person in the n made under this part unless that person has actual knowledge of the revocation. 75-2-1104. Directive for medical services. (1) A person 18 years of age or older may execute a directive under this pat's medical record the time, date, and place when notice of a written revocation was received. (3) There is no criminal or civil liability on the part of any person for failing to act upon a revocatio only upon receipt by the attending physician and other providers of medical service of a written revocation under Subsection 75-2-1111 (b) or (c). The attending physician shall record in the declaranyears of age or older who signs and dates a written instrument confirming that the expression of intent was made. (2) Any oral revocation not otherwise known to the attending physician becomes bindingy the declarant or by a person signing on behalf of the declarant or acting at the direction of the declarant; (c) oral expression of an intent to revoke the directive in the presence of a witness 18 and by: (a) being obliterated, burned, torn, or otherwise destroyed or defaced in any manner indicating an intention to effect revocation; (b) a written revocation of the directive signed and dated b the declarant if the declarant has signed it personally, or by the person or persons who signed a directive on behalf of a declarant, based on changed circumstances or conditions or a change of mind,ath, and where the application of life sustaining procedures serve only to postpone the moment of death of the person. 75-2-1111. Revocation of directive. (1) A directive may be revoked at any time by10) "Terminal condition" means a condition caused by injury, disease, or illness, which regardless of the application of life sustaining procedures, would within reasonable medical judgment produce deities, intermediate care facilities, intermediate care facilities for the mentally retarded, residential health care facilities, and facilities owned or operated by health maintenance organizations. (al services" includes all persons licensed to provide medical services and all health care facilities, including hospitals, psychiatric hospitals, home health agencies, hospices, skilled nursing faciltive function as diagnosed by two physicians, one of whom shall be the attending physician, in accordance with reasonable medical judgment. Information & Instructions ­ Page 2 (9) "Provider of medicresent and the person totally lacks higher cortical and cognitive function but maintains vegetative brain stem processes for which there exists no reasonable expectation of regaining significant cogni procedure which is intended to provide comfort care or to alleviate pain. (8) "Persistent vegetative state" means a state of severe mental impairment, in which only involuntary bodily functions are plects in the declaration to exclude artificially administered nutrition and hydration. (b) Life sustaining procedure does not include the administration of medication or the performance of any medicalany medical procedure or intervention which would in the judgment of the attending physician serve only to prolong the dying process; and (ii) artificial nutrition and hydration unless the declarant eily executed by or on behalf of a person in accordance with the requirements of this part. (6) "In writing" means any printed or hand written directive. (7) (a) "Life sustaining procedure" means: (i) ns a person 18 years of age or older who has signed or directed the signing of any directive, or for whom a directive has been signed under this part. (5) "Directive" means a written document voluntarspoon or bottle feeding. (3) "Attending physician" means the physician selected by or assigned to a person, who has primary responsibility for the treatment and care of the person. (4) "Declarant" meared to chew or swallow voluntarily, including nasogastric tubes, gastrostomies, jejunostomies, and intravenous infusions. Artificial nutrition and hydration does not include assisted feeding, such as behalf of a provider of medical services. (2) "Artificial nutrition and hydration" means supplying food and water through a conduit such as a tube or intravenous line, where the recipient is not requi useful excerpts from the Utah Statutes relating to Living Wills. 75-2-1103. Definitions. As used in this part: (1) "Agent" means any director, officer, employee, or other person authorized to act on To Physicians And Providers Of Medical Services (Living Will). This Utah Living Will is based on Title 75 Chapter 2 Section 1103 et. Seq. of the Utah Statutes . For your convenience, we have includedInformation and Instructions Utah Living Will This package contains (1) Information and Instruction for Utah Directive To Physicians And Providers Of Medical Services (Living Will); (2) Utah Directive Utah