VA Form 10-0137 VA Advance Directive: Durable Power of Attorney for Health Care and Living Will

How to Fill Out VA Form 10-0137?

1. Enter your full name, last four digits of your Social Security Number (SSN), full address, and home, work, and mobile phone numbers in Part I ("Personal Information"). Every page of the form must contain your full name and the last four digits of the SSN.
2. Part II ("Durable Power of Attorney") is for appointing a specific person to make healthcare decisions for the individual when they are no longer able to do so. This person is referred to as a health care agent. This person should be aware of the individual's values and choices regarding their health care. The individual can name two healthcare agents. The form requires their full names, addresses, and home, work, and mobile phone numbers.
3. Part III ("Living Will") is for indicating the preferences in case the person is unable to make healthcare decisions anymore. Section A of this part is for indicating preferences for life-sustaining treatments, including CPR, mechanical ventilation, kidney dialysis, artificial nutrition, and hydration. Section B is for listing preferences for a severe mental health condition. Section C can contain additional preferences. Section D is for specifying, how strict these preferences should be followed. Sections B and C are optional.
4. Part IV ("Signatures") is for signatures: the signature of the individual and signatures of two competent witnesses who personally witnessed the signing of the advance directive. Both witnesses should be present when the individual signs the form. The witnesses should either know the individual personally or be shown proof of their identity before signing the form. A health care agent of the individual cannot be a witness.
5. The form should be notarized in Part V in order to be legally binding outside the VA health care setting.

Where to Mail VA Form 10-0137?

The completed copy of VA Form 10-0137 should be presented in person or mailed to the individual's VA health care provider for medical records. Provide your health care agent with a copy, as well as and any person who is involved in the individual's healthcare decision. Keep the original of the completed form for your records.

Not what you were looking for? Check out these related topics:

• VA Form 10-0137A, Your Rights Regarding Advance Directives;
• VA Form 10-0137B, What You Should Know About Advance Directives.