Advance Care Plan (ACP) Enrollment

Please carefully review and complete all sections to document your healthcare wishes.

Introduction to Advance Care Planning

An Advance Care Plan (ACP) is a legal document that allows you to:

Appoint (Select) your medical power of attorney or legal healthcare agent to serve as your voice when you
are not able.
Share your goals / values / preferences for your medical healthcare to help guide your treatment plans when you are not able.

Your Rights

Facilitate your own healthcare decisions.
Accept or refuse medical treatment.
Create an Advance Care Plan.

Advance Care Plan Requirements:

The individual has the medical capacity to make healthcare decisions.
The ACP must be in writing.
Signed and dated by the individual named in the document and by two witnesses over the age of 18.

Virginia State Law (Virginia Code, §54.1-2982 to -2993) does not require Advance Medical Directives to be notarized, written on any special form, or drafted by an attorney. Advance Medical Directives are voluntary and you may refuse to implement one if you have a conscience objection.

Use of This Kiosk: We are providing this kiosk a means for you to complete your Advance Care Plan. Please navigate to the next page to start entering your selections.

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  "PersonalContactInformation": {
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    "Address": "",
    "City": "",
    "State": "",
    "ZipCode": null,
    "Phone": "",
    "SSNLastFour": "",
    "EmailAddress": "",
    "Role": "",
    "DidCompleteStep": false
  },
  "MedicalPowerOfAttorney": {
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    "HasSecondaryAgent": false,
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  "QualityOfLife": {
    "QualityOfLifeDefinition": null,
    "QuestionOneRank": null,
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}