Spiritual Care Advance Directive for ______________________________________To encourage, facilitate, & authorize the partnership of care between my health care providers & my faith community/spiritual care providers and in order to receive appropriate and timely spiritual care, I voluntarily request and authorize my doctor and/or the staff of

________________________________________________________________________________(Name of health care organization, health care provider(s) and/or senior living facility)to notify my faith community or spiritual provider named below as soon as reasonably possible in the event of one of the following as initialed by me, my next of kin, or legal representative and to share with them the medical information (PHI) needed to determine appropriate spiritual care for me._____ if I am admitted to a hospital_____ if I am sent to a hospital emergency department_____ if I am transferred to another health care facility_____ if I (or my family) have been informed of significant changes to my mental or physical health_____ if I (or my family) have been informed that end of life treatment options need to be discussed_____ if I (or my family) have been informed that it appears I am near death_____ upon my death_____ at my, my family, or legal representative’s request_____ Other:______________________________________________________________________

I understand I may amend or revoke the above at any time in writing. I agree to hold harmless the facility(ies) named in this document and their staff and my doctor(s) if for any reason they fail to initiate the notifications authorized above.

Signed______________________________________________________________Date:_______________

Or, signed on behalf of_____________________________________________________________________

By__________________________________________________________________Date:_______________

Relationship;_____________________________________________________________________________

I revoke this Advance Directive:___________________________________________Date:_______________

Witnessed by or confirmed by (Health Care Provider or Organizational Representative Signature/Title)

____________________________________________________________________Date:_______________

Faith Community Name:__________________________________________Phone #:_________________

Spiritual Care Provider(s) Name(s), Phone #s & Email Addresses:

________________________________________________________________________________________

________________________________________________________________________________________Or, the current Spiritual Provider for the faith community named above.

Please note the faith community and its care providers are NOT to make public or disclose the information provided by my health care providers to others without my further consent, or if I am unable, the consent of my next of kin or legal representative.

Copy: __ for oneself __ family __ for the health care provider __ for faith community/provider

Please review the “Information and Instruction” page before completing this form.

spiritualcareadvancedirective.com ©2010 Rev. James H. Cunningham