Terminal Illness Templates

Use this Utah-specific document, which is a written statement of what the patient wants to happen in the event of a serious accident or illness. This document is primarily addressed for the medical personnel and focuses on the type of care the patient wishes to have in situations of terminal illness or incapacitation.

Print out this will to pre-organize your health care in a potential scenario, prevent major arguments between your family members, control any necessary medical treatments and procedures and reduce potential extra medical bills in the state of Washington.

Fill out this will to determine your health care treatment in a potential scenario, prevent major arguments between your family members, control any necessary medical treatments and procedures and reduce potential extra medical bills.

This form is used for creating an advance care plan in Arkansas. It helps individuals outline their medical and end-of-life preferences, ensuring their wishes are respected if they become unable to communicate them.

This form is used for physicians in Illinois to confirm a patient's terminal illness.

This document is for applying for a Registry Identification Card in Illinois for individuals diagnosed with a terminal illness. The card is valid for six months only.

This document provides information about the Medicare Hospice Benefit, which is a program that covers hospice care for terminally ill patients. It explains the eligibility criteria, services covered, and how to access this benefit.

This form is used for Waiving 60% of Joint Pension Entitlement due to Terminal Illness or Disability in Manitoba, Canada.

This form is used in Manitoba, Canada for obtaining consent to withdraw funds from a LIRA or LIF due to terminal illness or disability.

This Form is used for physicians in Colorado to provide a statement regarding a patient's life-limiting illness.

This form is used for notifying the HFS of Illinois Medicaid about a continuing benefit period and recertification of terminal illness for the hospice benefit.

This form is used to instruct health care providers to not do CPR for the patient if their heart stops beating.

This form is used for terminally ill residents of a Community Based Residential Facility (CBRF) in Wisconsin to waive hospice or home health services.

This type of form allows for an individual that resides in Florida to select themselves two agents that have the legal power to make medical decisions regarding the principal in emergency situations when the principal is not in a fit state to do so.

Residents of New Jersey may use this type of form when a principal wants to create a back-up option regarding their treatment and have another individual be able to make specific choices concerning treatment.

This form is used for recording the patient's request for Medical Assistance in Dying (MAID) in Newfoundland and Labrador, Canada.

This form is used for physicians in Wisconsin to certify or recertify a patient's terminal illness.

This form is used for creating an advance directive in Idaho, which allows individuals to specify their healthcare preferences in case they become unable to make decisions in the future. It helps ensure that their medical wishes are honored.

This document is used for certifying terminal illness for individuals seeking hospice care under the Louisiana Medicaid Program in Louisiana.

This document is used for Clinician Orders for DNR/CPR and other life-sustaining treatments in Vermont.

This Form is used for appointing a health care agent to make medical decisions on your behalf in Massachusetts.

This document provides a template for crafting a letter regarding end-of-life care decisions, particularly for clarifying preferences and wishes about medical and care measures during terminal illness or nearing death situations.

This type of document is used in Vermont and is available in English and Vietnamese. It is an Advance Directive short form, which allows individuals to specify their medical preferences and appoint a healthcare agent in case they are unable to communicate their wishes.

This form is used for reporting patient choice at the end of life by physicians in Vermont.