U.s. Living Will Registry Registration Agreement printable pdf download

U.S. Living Will Registry® Registration Agreement

Registrant’s Identifying Information (Please print clearly)

SOURCE CODE: 13115502

____________________

Name: First

Middle

Last

Suffix

_____________________

_______________

____________________________

____

Social Security #

______-______-_______

Date of Birth Month

____

Day

____

Year

_______ (4 digits)

Street Address

_________________________________________________________________

Apt #

___________

City:

State:

Zip Code:

_______________________________________

_____________

_______________________

Primary Phone

Alternate Phone

: (_______) ________ - ____________

: (_______) ________ - __________________

EMAIL address for Registrant or Emergency Contact:

_________________________________________________

* Annual update reminders will be sent via email (email addresses will not be shared or sold)

Emergency Contact Name:

Relationship:

______________________________________

______________________

Address:

________________________________________________________________________________________

Primary Phone

Alternate Phone

: (_______) ________ - ____________

: (_______) ________ - __________________

I,___________________________ ("Registrant" or “I”), authorize U.S. Living Will Registry®, with offices at 808 South Ave.

West, P.O. Box 2789 Westfield, NJ 07091-2789 ("Registry"), to electronically store a copy of my advance directive(s) provided to

Registry with this registration form or subsequently, including but not limited to a living will, health care proxy, durable power of

attorney for health care and/or financial matters, Medical or Physician Orders for Life-Sustaining Treatment (MOLST or POLST)

organ donation wishes and emergency contact information (“Advance Directives”). I further authorize the Registry to make available

a copy of the stored Advance Directive(s) to any health care provider or other person believed charged with giving effect to my

Advance Directive(s) or assisting in same, who requests it in conjunction with my care, provided such a request is consistent with the

Registry’s policies and procedures, or as deemed advisable by the Registry in an emergency situation, or as required by law. The

Advance Directive(s) that I am providing is my current, effective Advance Directive(s), and was signed and witnessed in accordance

with the law of the state of my residence.

I hereby authorize Registry to make available a copy of my Advance Directive(s) to hospitals, physicians, or other health care

providers involved with my care, or anyone who has access to the wallet identification (“ID”) card provided to me by Registry. I

understand this authorization is voluntary. I agree to notify Registry immediately if I decide to revoke or change my Advance

Directive(s) stored with Registry and to provide Registry with a copy of any additional Advance Directive(s) that I sign. I understand

that unless I terminate this authorization or inform Registry of revocation or changes to my Advance Directive(s), the Advance

Directive(s) stored with Registry will be provided to health care providers in accord with Registry policies and practices.

I understand that Registry makes no representations about the validity of my Advance Directive(s) under federal or state law

and that Registry bears no responsibility for the actions taken by health care providers in relation to my Advance Directive(s). I

hereby waive any and all legal claims against Registry for the actions and omissions by any health care providers who receive a copy

of my Advance Directive(s) from Registry and for any damages arising from the transmission or disclosure of the Advance

Directive(s) I provide to Registry. Registry shall not be liable for the loss, destruction or unavailability of all or part of my Advance

Directive(s).

I understand that I may revoke this authorization at any time by giving written notice of my revocation to Registry. This

Agreement will remain in force until revoked by me or until terminated in accordance with the agreement between me and Registry or

until registration is cancelled pursuant to the Registry’s policies and procedures. When the Agreement is terminated, I understand that

Registry will remove my Advance Directive(s) from its files.

I understand that anyone who gains access to my wallet ID card provided by Registry can use it to gain access to my Advance

Directive(s) and personal information stored with Registry, and I will not hold the Registry liable for such authorized or unauthorized

access.

I hereby agree to the terms set forth herein.

X___________________________________________ DATED: _____/_____/_____

Signature of Registrant

Registration Agreement 4-9-2012

U.s. Living Will Registry Registration Agreement

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