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The OMB Control No. for this information collection is 2900-0556. VA FORM JUL 2015 10-0137 Page 1 of 7 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. OMB Approval Number 2900-0556 Estimated Burden Avg 30 minutes Expiration Date 10/31/2017 VA ADVANCE DIRECTIVE DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL This advance directive form is an official document where you can write down your preferences for your health care. I am not financially responsible for the care of the person making this advance directive. To the best of my knowledge I am not named in the person s will. Name Printed or Typed 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. DATE SIGNATURE B - WITNESSES SIGNATURES Two people must witness your signature. VA employees may be witnesses if they are members of l The Chaplain Service l The Social Work Service l Nonclinical employees e.g. Medical Administration Service Voluntary Service or Environmental Management Service Other employees of your VA facility may not sign as witnesses to your advance directive unless they re in your family. 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 l Name specific people to make health care decisions for you l Describe your preferences for how you want to be treated care When you complete this form it s important that you also talk to your doctor family and other loved ones who may help to decide about your care. You should explain what you meant when you filled out the form* A health care professional can help you with this form and can answer any questions that you have. 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. PART I PERSONAL INFORMATION NAME Last First Middle LAST FOUR DIGITS OF SSN 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 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 at http //www. gpoaccess. gov/privacyact/index. html* You may choose to fill out this form or not. But without this information VA the benefits you are entitled to receive.