Advance care planning means thoughtfully considering a time when you may not be able to make healthcare decisions for yourself. This time may never come, but the thinking, sharing, and recording you have done will still be valuable. Advance care planning can help clarify your values and give you peace of mind, and put your loved ones at ease. 


How do I start the conversation?

Whether you're talking about your own wishes or trying to find out the wishes of someone close to you, getting started on a care-planning conversation can be difficult. Here's a guide to help:

Do you have an Advance Directive?

An advance directive is a form that provides a simple way for you to let your family, friends, and physicians know your healthcare choices, including any types of special treatment you want, at the end of their life. It also allows you to appoint a person to help make decisions on your behalf you’re unable to do so. Download the advance directive form: English   Spanish

You can submit an advance directive at any time to store in your medical record. We can accept these at any Intermountain location in our Health Information Management/Medical Records departments. Simply send a copy of a new or existing advance directive by mail, fax, or e-mail as follows:

  1. Bring advance directive forms to our Health Information Management/Medical Records department at any Intermountain hospital
  2. Mail a copy to: PO Box #70539, Salt Lake City, UT 84170
  3. E-mail a copy (with the advance directive document as an attachment) to: Advance.Directive@imail.org
  4. Fax: Attention: Advance Directive, 801-442-0484

Advance Care Planning Forms and Documents

Intermountain's Advance Care Planning Booklets can help you with the planning process. These booklets include legal forms used as part of advance care planning. Please choose the booklet that is appropriate for the state in which you live and receive medical care:

Below are the legal documents most commonly used as part of the advance care planning. We encourage you to use one of these documents to record your wishes. Please read the descriptions of the forms to select the one that best meets your needs at this stage in your life.

UTAH Forms What it does... When it takes effect...

Utah Advance Health Care Directive
English  Spanish

This form can be filled out at any time.

This form allows you to:
  • Identify the person you want to make healthcare decisions for you if you can't take part in decision-making. This person is your healthcare agent.
  • Gives your healthcare agent or medical team the right to withhold or withdraw life-sustaining treatments in certain circumstances, which you can identify on the form.
The Utah Advance Health Care Directive takes effect when you can't make medical decisions for yourself for any reason.

Physician Order for Life Sustaining Treatment (POLST) *
English  Spanish

This form is filled out in consultation with your medical team, usually in response to a specific healthcare threat.

Directs the medical team regarding the care and treatment you want provided or withheld. The POLST is transferable, meaning that the instructions apply no matter where you're cared for: hospital, home, skilled nursing facility, or hospice. The POLST takes effect immediately, as soon as the order is completed and signed.
* NOTE: This document is only a sample copy; the form is filled out in consultation with your medical team.

IDAHO Forms
What it does... When it takes effect...

Idaho Living Will and Durable Power of Attorney  

This form is often filled out before you're faced with serious illness.

Gives a medical team the right to withhold or withdraw life-sustaining treatments in certain circumstances; also can by used to identify the person(s) you want to make healthcare decisions for you if you can't take part in the decision-making. The Power of Attorney also gives that person (called your healthcare agent) the legal power to do so. You have a terminal illness and can't make decisions for yourself OR you are in a chronic vegetative state; the Power of Attorney takes effect when you can't make medical decisions for yourself for any reason.
Physician Orders for Scope of Treatment (POST) Instructions*

This form is filled out in consultation with your medical team, usually in response to a specific healthcare threat.
Directs the medical team regarding the care and treatment you want provided or withheld. The POST is transferable, meaning that the instructions apply no matter where you're cared for: hospital, home, skilled nursing facility, or hospice. The POST takes effect immediately, as soon as the order is completed and signed.
* NOTE: These documents are only sample copies; generally you would not need both documents.

If you choose to complete an advance directive form, please be sure to print your full name and date of birth on the document. We advise you to store the original document in a location in your home where it can be easily retrieved by you or your family members if it is needed. Additionally, we encourage you to send a copy of the document to Intermountain Healthcare. If you provide Intermountain with a copy, we will store the document in your electronic medical record. In this way, it will be available at any of our Intermountain facilities or clinics, if it is needed at some point in the future—in one year or in twenty. You can change your wishes at any time by completing a new advance directive and sending Intermountain Healthcare a copy of the updated document.

You can submit copies of advance directives to Intermountain Healthcare any of the following ways:

Mail
Intermountain Advance Directives
PO Box 70539
Salt Lake City, UT 84170

Email
Advance.Directive@imail.org
(Send the document as an attachment)

Fax
801-442-0484, Attn: Advance Directive​

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