Free HCDR_Form_tri_fold.pmd - Idaho

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Idaho Health Care Directive Registry
I want to:

Registration Form

Store a copy of my health care directive in the Registry. Replace my health care directive now in the registry, file number __________, with a new one. Remove my health care directive from the registry. Request a replacement wallet card (no change to my health care directive now in the Registry) The personal information below is provided with the understanding that it will be stored in the Idaho Health Care Directive Registry. I certify that the Health Care Directive and Durable Power of Attorney that accompanies this Agreement is my currently effective health care directive, and was duly executed, witnessed and acknowledged in accordance with the laws of the State of Idaho. I understand that use of the health care directive registry is entirely voluntary, and no one is required to register their living will or durable power of attorney with the Idaho Secretary of State. Registration or non-registration of these types of documents has no effect upon their validity. Registration only makes these documents more accessible in time of emergency. Fill in all blanks of this Agreement and enclose your Health Care Directive with this Agreement. We recommend that your Directive be witnessed or notarized.
Last Name First Name Middle Name

Address

Date of Birth

Telephone Number

City

State

Zip Code

Address to return wallet card and documents (if different from address above)
Last Name First Name Middle Name

Address

City

State

Zip Code

Signature of person completing this Agreement Registrant

Printed Name Date

Sign and date this Agreement and deliver it to the Office of the Idaho Secretary of State in person or by mail. Idaho Secretary of State 304 N 8th Street Room 149 700 West Jefferson Street Room 203 Boise ID 83720-0080