Documents and Instructions

Before You Begin

If you have a question about the terminology used in any of the following documents, please use this helpful resource from the National Institute of Health. There is an Advance Care Planning section with a glossary of terms and frequently asked questions section to help you get started. Here is another great resource that outlines the difference between Hospice and Palliative Care. 

Once You Have Completed Any of the Below Documents 

• Keep the original documents
• Make a copy of the original documents and provide one to your primary care physician, the local hospital where you you would receive care if needed, and your patient advocates. 

To Provide a Copy to Munson Healthcare

• Scan or take a photo of each page and email to MMC-HIM-AMD@mhc.net
• Fax a copy to HIM at 231-935-6615
• Mail a copy to MMC Health Information Management Department, 1105 6th Street, Traverse City, MI 49684

Advance Directive

An advance directive (also referred to as a durable power of attorney for healthcare or a patient advocate designation) is a legal document that allows you to designate the person(s) you trust most to speak for you only during times when you are unable to make medical decisions for yourself.  This document also allows you to list your treatment preferences should you desire to do so.   This document can be changed or revoked at any time.  It's important to know that if you choose not to complete an advance directive, family members or the courts may be called upon to make decisions on your behalf. 

Download the Advance Directive PDF

A Temporary Delegation of Parental Rights and Consent to Medical Treatment of a Minor or Dependent Adult

This form is valid for 6 months and is useful during times when you are going to be separated from your children or those under your care. By law, hospital emergency personnel cannot provide treatment in the event he or she becomes ill or injured, except in life or death situations, without parental/guardian authorization. Completing this form allows you to name authorized persons a limited power of attorney to act for you on behalf of your minor child/children or dependent adult. A completed form should be provided to the hospital in advance or accompany the people you have authorized to act for you. 

Download the temporary delegation

Do-Not-Resuscitate (DNR) Order

This document is an out-of-hospital medical order that tells EMS personnel that you do not want CPR.  This is a document that is part of the advance care planning process and is intended for adults or minors who are living with an advance illness or signification impairment and who prefer to die as naturally as possible.  Place this document on your refrigerator and wear a DNR medical alert bracelet so EMS knows what your medical care decisions are.  These can be purchased at most pharmacies or ordered online at StickyJ.com and you must provide a copy of your DNR order signed by your physician in order to purchase a DNR medical alert bracelet.

NOTE: If you have an out-of-hospital DNR document completed, this does not authorize a DNR order in the hospital setting. Because you can change your mind at any time, hospital personnel will ask you what your wishes are for CPR on each Emergency Department visit. If you have a DNR treatment preference written in your advance medical directive or medical durable power of attorney, this does not serve as a DNR order and EMS personnel cannot act on an advance medical directive. 

Download the Do-Not-Resuscitate Order PDF

DNR Form Instructions

Michigan Physician Order for Scope of Treatment (MI-POST)

This document is also an out of hospital medical order that tells healthcare professionals what your decisions are about cardiopulmonary resuscitation (CPR) and other medical care. This is a document that is part of the advance care planning process and is intended for people living with serious advanced illness or frailty who have a shortened life expectancy of a year or less. Place this document on your refrigerator so EMS knows what your medical care decisions are.

Michigan Physician Order for Scope of Treatment (MI-POST) 

Dementia Directive

Today, dementia affects many people. It can take several years to progress and cause numerous health and function issues, including the inabilities to communicate or make decisions. Planning ahead for the medical treatment you would prefer is important. This Dementia Directive is a specifically-designed communication tool that outlines the kind of medical care and quality of life you would want if you develop or have moderate or severe dementia. Because an advance directive or medical durable power of attorney document cannot always address the unique circumstances associated with the progression of dementia, we recommend using the Dementia Directive in conjunction with the Advance Medical Directive and Treatment Preferences. Doing this now, before dementia progresses, will help your loved ones and your healthcare team to provide the best care possible based on your values and goals for living a meaningful life. 

NOTE: A living will is not legally binding in Michigan and therefore should accompany the Advance Medical Directive and Treatment Preferences.

Visit the Dementia Directive website

HIPAA Release Form

HIPAA Privacy allows Munson Healthcare (MHC) and business associates to disclose the minimum necessary protected health information (PHI) to family members or friends who are responsible for or appear to be involved in your medical care or your health care bills. MHC may also notify your family or friends of your location and condition in the event of an emergency or disaster.

Download the HIPAA release form