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VA Form 10-0137 Printable, Fillable in PDF – Veteran Affairs (VA) Form 10-0137, VA Advance Directive: Durable Power of Attorney for Health Care and Living Will, is a Power of Attorney (POA) form that is used by the United States Department of Veterans Affairs (VA). This form is used to appoint a healthcare representative who will be able to act on behalf of the individual if they are no longer able to make choices on their own. As long as the person is healthy and in good mental health, the information submitted on this form may be updated or canceled at any point in time.
Detailed Instructions On How To Complete VA Form 10-0137
- Part I requires you to provide your entire name, the last four digits of your Social Security Number (SSN), your full address, as well as your home, work, and mobile phone numbers (“Personal Information”). Every page of the form must include your entire name as well as the last four digits of your Social Security number.
- Part II (“Durable Power of Attorney”) is used to appoint a specified person to make healthcare choices on the individual’s behalf when the individual is no longer able to do so themselves. A health care agent is the title given to this individual. This individual should be knowledgeable of the individual’s personal beliefs and health-care preferences, and they should be able to communicate with them. The person may name up to two different healthcare professionals. Their entire names, addresses, as well as their home, work, and mobile phone numbers, are required on the form.
- Part III (also known as a “Living Will”) is used to express healthcare choices if the individual is no longer able to make decisions for themselves. A preference for life-sustaining procedures such as cardiopulmonary resuscitation, mechanical ventilation, renal dialysis, artificial feeding, and hydration should be expressed in Section A of this section. Section B contains a list of preferences for those suffering from a serious mental illness. Additional preferences may be included in Section C. Specifying how strictly these preferences should be adhered to is the purpose of Section D. Sections B and C are not required to be completed.
- Part IV (“Signatures”) contains the signatures of the individual signing the advance directive, as well as the signatures of two competent witnesses who were present at the time of the signing of the advance directive. When the person signs the form, both witnesses should be present to observe his or her signature. Before signing the document, the witnesses should either know the subject directly or be provided identification that verifies their identity. A witness cannot be a representative of the individual’s healthcare provider.
- If the form is to be legally enforceable outside of the VA health care context, it should be notarized in Part V of the form.
What Address Should VA Form 10-0137 Be Sent To?
When the individual’s VA health care provider requests medical records, the completed copy of VA Form 10-0137 should be submitted in person or sent to the physician. Provide a copy of this document to your health care agent, as well as to anybody else who may be involved in the individual’s healthcare choice. Keep a copy of the completed form for your records, as well as the original.