Acknowledgment of Receipt for Advance Directives
Document that the resident/legal representative has been informed in writing, in a language understood by the resident/legal representative, of his/her rights and receipt of such documents for placement in the medical record.
Is also provides for the resident/legal representative to choose not to formulate Advance Directives and request effort to prolong life/provide life-sustaining treatment.
Includes:
• Living Will
• DNR
• DNH
• POLST/MOLST or POST/MOST (acronym depends on state designation) Organ Donation
• Autopsy Request
• Medication or Other Treatment Restrictions
• Tube Feeding wishes
• Intubation/Ventilator wishes
• Other Advance Directives
Top punched version of this form is no longer available.
- Size:8 1/2" x 11" detached
- 2-part version: White/Canary carbonless stock
- Punched 5-holes side
- Black ink
- 100 per pack