Idaho Advance Directive

Information you will need

• Principal Name
• Withhold or Provide Treatment
• POST Form
• Advance Directive Date
• Principal Address
• Agent Address
• Agent Telephone Number
• Additional Statement
• First Alternate Agent Name
• Second Alternate Agent Name
• Third Alternate Agent Name
• First Alternate Agent Address
• Second Alternate Agent Address
• Third Alternate Agent Address
• First Alternate Agent Telephone Number
• Second Alternate Agent Telephone Number
• Third Alternate Agent Telephone Number
• Principal City and State
• Initial: Only Hyrdration
• Initial: Only Nutrition
• Initial: Nutrition and Hydration
• Nutrition and Hydration
• Initial: Withhold or Withdraw All Medical Treatment
• Initial: Nutrition and Hydration Only

…and 5 more fields in the PDF.

Completed by the agent and the provider and the employee.

The form includes 1 signature line.