UTAH ADVANCE HEALTH CARE DIRECTIVE Utah Advance Health Care Directive Pursuant to Utah Code Sections 75-2a-100 et seq. Part I: Allows you to name another person to make health care decisions for you when you cannot make decisions or speak for yourself. Part II: Allows you to record your wishes about health care in writing. Part III: Tells you how to revoke or change this directive. Part IV: Makes your directive legal. My Personal Information Name: Address: Address: Telephone: Cell Phone: _ Birth Date: _ Part I: My Agent (Health Care Power of Attorney) A: No Agent If you do not want to name an agent, initial the box, below, then go to Part II; do not name an agent in B. or C. below. You are not required to name an agent, and no one can force you to name an agent. I do not want to choose an agent. B: My Agent Agent's Name: _ Street Address: City, State, Zip: _ Home Phone: _ Cell Phone: _ Work Phone: C: My Alternate Agent This person will serve as your agent if your agent is unable or unwilling to serve Agent's Name: _ Street Address: _ City, State, Zip: _ Home Phone: _ Cell Phone: _ Work Phone: 89