Advanced Directives "*" indicates required fields LocationACMSPCMSLDSEmail* First Name* Last Name* What is an Advance Directive?Advance Directive means that you have chosen a person to make medical decisions for you if you are unable to make them yourself. An "Advance Directive" can be a Living Will, a Durable Power of Attorney for Health Care, or other evidence of your wishes concerning health care decisions. A "Living Will" is a document that specifies what type of medical treament you would like taken if you are unable to make decisions for yourself. A "Durable Power of Attorney for Health Care" is a document where you designate someone as your agent to make health care decisions for you if you are unable to make such a decision.Do you have an Advance Directive* Yes No If Yes, we need a copy of your Advance Directive for our records.Would you like information about Advance Directives?* Yes No Signature:* (Patient, Parent, Guardian)ACMS Representative: Date MM slash DD slash YYYY Comments:CaptchaNote: It is the policy of Amite County Medical Services, Inc. to make available information concerning Advance Directives and to note such in individual charts; however, ACMS does not honor Advance Directives at our facilities due to limited ability to assess specific patient condition and prognosis.CommentsThis field is for validation purposes and should be left unchanged.
