Washington Advance Directive

Information you will need

• Special Provisions
• Grantor Signing Day
• Grantor Signing Month
• Grantor Signing Year
• Grantor Name
• Health Care Directive Day
• Health Care Directive Month
• Health Care Directive Year
• Additional Directions
• Notary Public: County
• Notary Public: Day
• Notary Public: Month
• Notary Public: Year
• Notary Public: Grantor Name
• Notary Public: Title of Office
• Notary Public: Commision Expiration Date
• First Health Care Agent Name
• First Health Care Agent Address
• First Health Care Agent City
• First Health Care Agent State
• First Health Care Agent ZIP Code
• First Health Care Agent Telephone Number
• Second Health Care Agent Name
• Second Health Care Agent Address

…and 11 more fields in the PDF.

Completed by the agent and the provider and the employee.

The form includes 1 signature line, a notary acknowledgment, a witness section.