Advance Directives Form – Behavioral Health

PM Form 3.12.1

THIS FORM MUST BE COMPLETED AND PROMINENTLY DISPLAYED IN THE BEHAVIORAL HEALTH MEDICAL RECORD
Section I.

Advance Directives Information Provided to Behavioral Health Recipients (to be checked and initiated by the consumer)

I have been provided written information about Advance Directives via the Member Handbook.
Consumer Initials*
Date*
MM slash DD slash YYYY
I have been provided a verbal explanation about Advance Directives.
Consumer Initials*
Date*
MM slash DD slash YYYY
I have been provided the Advance Directive Resources sheet as a helpful tool in developing an advance directive.
Consumer Initials*
Date*
MM slash DD slash YYYY
Section II. Advance Directives Development

(to be filled out by the Assigned Clinician)
Behavioral Health Recipient has developed an Advance Directive.
- Yes
- No
Date
MM slash DD slash YYYY
If No, stop here and let the behavioral health recipient know that assistance in developing an Advance Directive is available
If an Advance Directive has been executed (developed), is it in the behavioral health medical record?
- Yes
- No
If Advance Directive has been executed, but is not filed in the behavioral health medical record, please mark the applicable box below:
- Behavioral Health Recipient does not wish to have it filed in the behavioral health medical record
- Clinical Liaison/Case Manager has asked for a copy, but has not been provided one
- Other:
Other
To facilitate coordination of care:
- Has a copy of an executed Advance Directive or refusal been sent to the Behavioral Health Recipient’s PCP?
Section III. Advance Directives Enactment/Execution
Has the Advance Directive document ever been acted on?
- Yes
- No
Date
MM slash DD slash YYYY
If Yes, have all appropriate parties been notified?
- Yes
- No
Yes (specify who)
No (describe why not)
Staff Signature:

Signature:

Date:

Δ

We are here to help

NATIVE HEALTH is here to provide high quality, patient-centered medical, dental, behavioral health, WIC and wellness programs when you need us.

View our services

Join Our Newsletter

Name*
First Last
Email*
Name
This field is for validation purposes and should be left unchanged.

Δ

NATIVE HEALTH received the HRSA Patient Centered Medical Home badge. Community Health Quality Recognition badges recognize Health Center Program awardees that have made notable quality improvement achievements.

NATIVE HEALTH Central

4041 North Central Ave., Bldg. C
Phoenix, Arizona 85012
P: (602) 279-5262
F: (602) 279-5390

NHW Community Health Center

2423 West Dunlap Ave. Suite 140
Phoenix, Arizona 85021
P: (602) 279-5262
F: (602) 279-5361

NATIVE HEALTH Mesa

777 West Southern Ave.
Mesa, AZ 85210
P: (602) 279-5262
F: (480) 264-5222

Services

Make an appointment
Request transportation
Health Coverage Assistance
Our services

Advance Directives Form – Behavioral Health

PM Form 3.12.1

THIS FORM MUST BE COMPLETED AND PROMINENTLY DISPLAYED IN THE BEHAVIORAL HEALTH MEDICAL RECORD

Section I.

Advance Directives Information Provided to Behavioral Health Recipients (to be checked and initiated by the consumer)

Section II. Advance Directives Development

Section III. Advance Directives Enactment/Execution

Staff Signature: