How to Fill Out the Utah Advance Health Care Directive Form

To fill out the Utah advance health care directive form, download the statutory form from the Utah Commission on Aging, complete Part I to name a health care agent (and an alternate), complete Part II to record your treatment wishes, then sign and date the document in the physical presence of one qualified adult witness. Notarization is not required. The form is codified at Utah Code 75A-3-303 and combines a living will and health care power of attorney into a single document.¹²

Where to Get the Form

The official statutory form is a free PDF from the Utah Commission on Aging.² University of Utah Health and many Utah hospitals also keep copies in their patient services departments.³ The law says the statutory form “or a substantially similar form” is presumed valid, so you aren’t locked into one template. Using the official version avoids any argument about whether your document meets the requirements.⁴

Part I: Name Your Health Care Agent

Part I designates the person who will make medical decisions for you if a qualified provider determines you cannot decide for yourself. You aren’t required to name an agent. If you’d rather only document treatment preferences, the form has an initial line for that choice. Naming someone is the practical heart of the document, though, because no written instructions can anticipate every situation a doctor might face.

For your primary agent, enter their full legal name, street address, and phone numbers for home, cell, and work. Choose someone who can stay steady under pressure and push back on providers when needed. A spouse, adult child, or close friend usually fits.

The form also provides space for one alternate agent, who steps in if the primary is unable or unwilling to serve.⁴ Fill in the same contact details. If your primary agent is traveling or unreachable during an emergency, the hospital needs someone else with immediate authority.

What Your Agent Can Do

Once activated, agent authority is broad. The default language lets your agent consent to, refuse, or withdraw any health care, including life-prolonging treatment such as tube feeding, antibiotics, CPR, and dialysis. It also covers mental health care, including convulsive therapy and psychoactive medications. Your agent can hire and fire providers, access your medical records, and authorize transfer between facilities.⁴

Paragraph F in Part I is where you can place limits on your agent’s authority. If there are treatments you absolutely want or absolutely refuse regardless of the situation, write them there. Your agent is legally bound to follow those restrictions.

When the Agent’s Authority Starts

Your agent has no power while you can still make your own decisions. Under Utah Code 75A-9-117, the agent’s authority begins only after a physician, psychologist, physician assistant, or advanced practice registered nurse examines you and formally documents in writing that you lack capacity to make health care decisions. That finding must state the cause and expected duration of the incapacity and must meet accepted professional standards.⁵ If you regain capacity, the agent’s authority stops.

Part I also includes an optional box to nominate a guardian if a court ever needs to appoint one. This is separate from the agent role, but stating your preference gives the judge guidance if the question arises.

Part II: Write Down Your Treatment Wishes

Part II records your treatment preferences. Even if you’ve named an agent, these instructions guide the agent and serve as a backstop if the agent can’t be reached. If you skipped the agent designation in Part I, this section carries your wishes on its own.

End-of-Life Options

The form asks you to choose between two options for end-of-life care when you have a progressive terminal illness or are close to death with little chance of recovery:

Option A, prolong life: use all available treatments, including tube feeding, antibiotics, CPR, and dialysis, to extend life as long as possible.
Option B, comfort care only: no life-prolonging interventions. Comfort care and routine treatment to keep you as comfortable and functional as possible, even if that care incidentally prolongs life.⁴

You initial the option you prefer and initial the specific triggering conditions: a progressive illness that will cause death, being close to death with unlikely recovery, or both. Read those triggers carefully. “Terminal illness” and “close to death” describe different clinical stages, and you can choose one without the other.

Organ and Tissue Donation

The form has a section to record donation wishes. You can authorize donation for transplant, for research, for both, or decline entirely. Putting it in writing spares your agent and family a difficult conversation during an overwhelming time.

Other Wishes

A blank section at the end of Part II is for anything the checkboxes don’t cover: hospice preferences, spiritual practices during hospitalization, blood transfusion preferences, where you want to receive treatment. Be specific. “I prefer to receive hospice care at home rather than in a facility” gives providers something they can act on. Vague phrases like “I want to be comfortable” add little to the form’s default language.

If mental health treatment preferences matter to you, spell them out here too. The agent authority section already covers convulsive therapy and psychoactive medications, but written instructions bind the agent to your specifics.⁴ For detailed psychiatric directions, Utah also has a separate Declaration for Mental Health Treatment covering psychoactive medication, convulsive therapy, and short-term admission for up to 17 days. That standalone document gives more granular control than the general directive.⁶

Signing and Witnessing

Part IV is where the directive becomes legally binding. You sign and date, and one adult witness signs alongside you. Utah does not require notarization.¹

The witness must be physically present when you sign and must be at least 18 years old.³ The disqualification list is long. Your witness cannot be:

The agent you just named in Part I.
A relative by blood or marriage.
Anyone entitled to part of your estate under a will, trust, life insurance policy, pay-on-death account, transfer-on-death deed, or intestate succession.
Anyone who benefits financially from your death, which reaches beyond heirs to business partners, creditors, and others with a financial stake.
A person directly financially responsible for your medical care.
A health care provider treating you, or an administrator at a facility where you receive care.

A friend, neighbor, or coworker with no financial connection to you is usually the safest pick.¹ If someone signs the document on your behalf at your direction (allowed if you physically cannot sign), that person is also disqualified from serving as witness.

After You Sign: Distribute and Store

A signed directive in a drawer doesn’t help anyone. Hand out copies right away:

Your agent and your alternate agent, so each has their own copy and knows what it says.
Your primary care physician, whose office will scan it into your electronic health record for other providers in the same system to see.
Hospitals or specialists you see regularly, especially if they use a different records system than your primary doctor.
Close family members, so they know the document exists and where to find it, even if they aren’t the agent.

Keep the original somewhere both secure and accessible, like a home filing cabinet or fireproof folder. A locked safe deposit box is a poor choice because your agent may not be able to reach it quickly during a crisis. A wallet card noting you have an advance directive and listing your agent’s contact information helps first responders.

Utah does not maintain a mandatory central registry for advance directives. Some private services and hospital systems offer electronic storage, but no statewide database exists that emergency departments can query automatically. Personal distribution and the wallet card do most of the work.

Changing or Revoking the Directive Later

You can revoke your directive at any time by any of these methods:

Writing “void” across the document.
Physically destroying it, by tearing, burning, or defacing it in a way that shows intent to revoke.
Directing someone else to write “void” on it or destroy it for you.
Signing a written revocation, dated and signed by you or by an adult acting at your direction.
Orally revoking it in the presence of a qualified witness, subject to the same disqualifications as the original signing.⁷

A new directive that conflicts with an older one automatically revokes the older version to the extent of the conflict, so filling out a fresh form effectively replaces the previous one.⁷

One automatic revocation catches people off guard. Divorce, annulment, or legal separation automatically revokes the designation of your spouse as agent, unless the divorce decree says otherwise or you specifically reaffirm your ex-spouse as agent afterward.⁷ After a divorce, if you want someone other than your ex making medical decisions, fill out a new directive promptly.

After revoking or replacing a directive, destroy old copies and notify your agent, alternate, physicians, and any hospital that has the document on file. Telling only your doctor verbally while old paper copies float around leaves room for a provider at another facility to rely on outdated instructions in an emergency.

What This Form Doesn’t Do

Two limits are worth knowing before you file the form away.

Paramedics generally cannot honor an advance directive or health care power of attorney in the field. Their job is to stabilize and transport. If you want a do-not-resuscitate order followed by EMTs, you need a Provider Order for Life-Sustaining Treatment (POLST), which is a medical order signed by both you and a physician, physician assistant, or advanced practice registered nurse. The POLST does not replace the advance directive; the two should be consistent.⁸

Utah also restricts advance directives during pregnancy. Under the prior statute (75-2a-123), a directive providing for the withholding or withdrawal of life-sustaining treatment had “no force during the course of a declarant’s pregnancy,” though the agent designation itself remained effective. A pregnant declarant’s written instructions to stop life support could be overridden even while the agent kept authority over other decisions. If you could become pregnant, discuss this with your agent so the scope of their authority in that situation is clear.

1
Utah Legislature. Utah Code 75A-3-301 – Advance Health Care Directive for Adult
2
Utah Commission on Aging. Advance Care Planning
3
University of Utah Health. Advance Directive
4
Utah State Legislature. Utah Code 75A-3-303 – Optional Form for Advance Health Care Directive
5
Utah Legislature. Utah Code 75A-9-103 – Presumption of Capacity
6
Utah Legislature. Utah Code 26B-5-315 – Declaration for Mental Health Treatment
7
Utah Legislature. Utah Code 75A-3-307 – Revocation of Advance Health Care Directive
8
Utah Commission on Aging. Provider Order for Life-Sustaining Treatment (POLST)