Utah Advance Health Care Directive Form


A Utah advance health care directive assigns an agent the responsibility of informing a physician of a principal’s medical wishes or determining their health care treatment if they cannot speak for themselves. A principal can become incapacitated for various reasons, including a severe brain or spinal injury, terminal illness, or disability. The principal’s physician must verify that they can no longer communicate before the agent has authority.

The form has four (4) parts: 1) agent information, 2) health care wishes, 3) revoking or changing a directive, and 4) signature(s). While the principal only has to complete the “signature(s)” section, they must enter as much information as possible. By filling out the document in its entirety, the principal provides the agent with clear instructions on carrying out their medical wishes. For example, the principal can authorize or deny treatment, such as:

  • Tube feeding;
  • Medication;
  • Cardiopulmonary resuscitation (CPR);
  • Dialysis; and/or
  • Mental health care (i.e., convulsive therapy or psychoactive medications).

This form can allow or deny an agent access to a principal’s medical and health care financial records. The principal can give the agent access to this information at signing or at the time of incapacitation. The agent can also choose the principal’s health care facility if permitted through this form. For example, an agent may have to decide where the principal receives treatment (i.e., hospital, nursing home, or long-term care facility).

The agent must follow the guidelines written in the form and instruct the physician of the principal’s wishes. A principal can also give the agent the ability to hire or fire health care providers, inquire about medication procedures, choose a health care facility, access medical records, and request consultations.

Laws: § 75-2a

Signing requirements (§ 75-2a-107(c)): Requires the presence of one (1) witness.