The Advance Directive Acknowledgement emerged from the 1990 Patient Self-Determination Act, which requires healthcare facilities to provide information about advance directives to patients. This document serves multiple purposes: it protects healthcare facilities by documenting their compliance with federal and state laws, ensures patients are informed about their rights to make future healthcare decisions, and maintains clear records of patient preferences regarding advance directives. The acknowledgement is typically required during hospital admissions, nursing home registrations, or when establishing care with new healthcare providers. The specific format and requirements vary by state, but all versions must comply with both federal regulations and local state laws governing advance directives.
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1. Facility Information: Details of the healthcare facility providing the acknowledgement
2. Patient Information: Identification and contact details of the patient
3. Acknowledgement Statement: Formal statement confirming receipt and understanding of advance directive information
4. Patient Rights Statement: Overview of patient rights regarding advance directives
5. Signature Block: Space for patient or representative signature and date
1. Witness Section: Required in some states for verification of signature - use when state law requires witness signatures
2. Notary Section: Space for notary verification - use when state law requires notarization
3. Healthcare Proxy Information: Details of designated healthcare proxy - use when patient has designated a healthcare proxy
1. State-Specific Advance Directive Form: Blank copy of the state's official advance directive form
2. Patient Rights Brochure: Detailed information about patient rights regarding advance directives
3. Facility Policies: Healthcare facility's policies regarding advance directives
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