This Alaska Living Will, also known as an Advanced Health Care Directive, is designed in accordance with the Alaska Statutes §§13.52.010-13.52.390. It allows individuals, herein referred to as the "Principal," to set forth their preferences regarding medical treatment in the event they are no longer able to communicate their wishes directly.
Please provide the necessary information in the spaces provided to ensure this document accurately reflects your health care decision preferences.
Principal's Full Name: _____________________________________________
Principal's Date of Birth: __________________________________________
Principal's Address: _______________________________________________
Selection of Health Care Agent
This section allows the Principal to appoint a trusted individual as their Health Care Agent, who will be authorized to make medical decisions on their behalf if they are incapacitated or otherwise unable to communicate their wishes.
Health Care Agent's Full Name: ____________________________________
Health Care Agent's Relationship to Principal: _______________________
Health Care Agent's Address: ______________________________________
Health Care Agent's Phone Number: ________________________________
Alternate Health Care Agent's Full Name (optional): ___________________
Alternate Health Care Agent's Relationship to Principal: _______________
Alternate Health Care Agent's Address: ______________________________
Alternate Health Care Agent's Phone Number: _________________________
Living Will Declarations
In this section, the Principal may declare specific preferences regarding life-sustaining treatment, artificial nutrition, and hydration, or other end-of-life health care decisions.
With respect to life-sustaining treatments, I declare the following: __________________________________________________________________________________________
Regarding the provision of artificial nutrition and hydration, I specify that: _________________________________________________________________________________
Other specifications related to my health care and end-of-life decisions include: __________________________________________________________________________________
Signature of Principal
I, the undersigned Principal, affirm that this Living Will reflects my desires concerning health care decisions. I sign this document willingly and under no undue influence.
Principal's Signature: ___________________________ Date: ________________
Principal's Printed Name: __________________________________________
Witness Declaration
To further validate this document, two adult witnesses, who are not the appointed Health Care Agent(s), relatives by blood or marriage, heirs, health care providers, or financially responsible for the Principal's medical care, must witness the Principal's signing of this document.
Witness #1 Signature: ___________________________ Date: ________________
Witness #1 Printed Name: ___________________________________________
Witness Address: __________________________________________________
Witness #2 Signature: ___________________________ Date: ________________
Witness #2 Printed Name: ___________________________________________
Witness Address: __________________________________________________