This advance directive form is an official document where you can write down your preferences for your health care. If someday you can’t make health care decisions for yourself anymore, this advance directive can help guide the people who will make decisions for you.

You can use this form to: 

• Name specific people to make health care decisions for you 

• Describe your preferences for how you want to be treated 

• Describe your preferences for medical care, mental health care, long-term care, or other types of health care

You may complete some, none, or all sections of this form. If you need more space for any part of the form, you may attach extra pages. Be sure to initial and date every page that you attach. You also must initial the sections you complete and sign the form. If you are unable to initial or sign the form because of a physical impairment, you can place an “X”, thumbprint, or stamp on the form instead of your initials and signature.

If a physical impairment prevents you from doing any of these things, you can ask someone else who is with you to sign, place an “X”, thumbprint, or stamp on the form. When you complete this form, it's important that you also talk to a member of your health care team, family, and other loved ones to explain what you meant when you filled out the form. A member of your health care team can help you with this form and can answer any questions that you have. 

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At VA, we recognize and respect the importance of privacy. Personal information that we collect is kept confidential to the extent provided by law. In accordance with the Privacy Act and applicable confidentiality statutes, VA will only disclose the information in its custody or control in the following circumstances: where the individual identifies the particular information and consents to its use; where disclosure of the information is required by law; or where the disclosure is otherwise legally permitted, including release for a purpose compatible with the purpose for which it was collected.

By law, VA must have your written permission (an "authorization") to use or give out your claim or benefit information for any purpose that is not permitted by all applicable legal authorities. You may revoke your written permission at any time, except if VA has already acted based on your permission.

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The Homeless Providers Grant and Per Diem Program was authorized by Congress in 1992 under Public Law 102-590 and gave the Department of Veterans Affairs (VA) authority to provide financial support to nonprofit organizations, or state and local governments, to establish programs to assist the homeless veteran population.

https://www.va.gov/homeless/gpd.asp