10-0137

VA Advance Directive: Durable Power of Attorney for Health Care and Living Will

Agency
VA
Revision
March 2024
Fillable fields
80
Pages
6
Official source
VA form page
Checked
October 20, 2026
Fill 10-0137 online
Page 1 of form 10-0137

VA Form 10-0137: VA Advance Directive, Durable Power of Attorney and Living Will

VA Form 10-0137 is the U.S. Department of Veterans Affairs advance directive, titled VA Advance Directive: Durable Power of Attorney for Health Care and Living Will. VA's form page says to use it to give specific people permission to make health care decisions for you, and to let VA health care providers know your wishes for medical, mental health, long-term, and other types of care.

The form calls itself an official document where you can write down your preferences for your health care. It says that if someday you can't make health care decisions for yourself anymore, it can help guide the people who will make decisions for you, and that you may complete some, none, or all of its sections.

The PDF has six pages: Part I for personal information, Part II for the Durable Power of Attorney for Health Care, Part III for the Living Will, Part IV for your signature and two witnesses, and an optional Part V for a notary public. VA's page lists VA Form 10-0137A, What You Should Know About Advance Directives, as a related form. You can fill out the PDF free in your browser on this page and download the result without an account.

Top of page 1 of VA Form 10-0137: VA Advance Directive, Durable Power of Attorney and Living Will, as printed by VA

What's on VA Form 10-0137

Part I: Personal information

Name, date of birth, street address, city, state and ZIP, and home, work and mobile phone numbers. The name and date of birth repeat at the top of every page.

Part II: Durable Power of Attorney for Health Care

Section A has two choices, initial only one: not appointing a Health Care Agent right now, or appointing a named person with their relationship, address and phone numbers. Section B names an alternate Health Care Agent.

Part III A: Life-sustaining treatments

For six situations plus an Other line, you initial Yes, I'm not sure, or No about life-sustaining treatments. The form gives CPR, a breathing machine, kidney dialysis and a feeding tube as examples.

Part III B to D: Other preferences

Optional mental health preferences, optional additional preferences such as social, cultural or faith-based ones, and a choice of whether the Living Will serves as a general guide or is followed strictly.

Part IV: Signatures

Your signature in ink and the date, certifying that the form accurately describes your preferences, then each witness's signature, date, printed name and address.

Part V: Notary public (optional)

Space for a notary's acknowledgment with the day, the county and state, the notary's signature, the commission expiration date and the seal.

How to complete VA Form 10-0137

  1. 1

    Fill in Part I

    Enter your personal information on page 1, then your name and date of birth at the top of each later page.

  2. 2

    Choose about a Health Care Agent

    Initial one box in Part II section A. The form says to skip to Part III if you don't wish to appoint an agent right now, and to use section B only for a second person.

  3. 3

    Record your Living Will choices

    Initial one box for each statement you answer in Part III. The form says you may attach extra pages for more space, and to initial and date every page you attach.

  4. 4

    Sign before two witnesses

    Sign and date Part IV A in ink. Each witness signs in ink, dates and prints their name and address in Part IV B.

  5. 5

    Talk it over

    The form says it's important to also talk to a member of your health care team, family and other loved ones to explain what you meant when you filled it out.

  6. 6

    Add a notary if needed

    Part V is optional. The form says a notary may be needed for it to be legally binding outside the VA health care setting.

Why fill Form 10-0137 on indox

You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.

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Where it goes and getting help

No mailing address

VA Form 10-0137 and its page print no mailing address. VA's page says the form is used to let VA health care providers know your wishes for care.

Help with the form

The form says a member of your health care team can help you with this form and can answer any questions that you have.

Releasing records

For general permission for VA to share medical records or health information with others, the form points to VA Form 10-5345, Request for and Authorization to Release Medical Records or Health Information.

Edition

The MAR 2024 edition carries OMB Approval Number 2900-0556, which expires 04/30/2027, and an estimated burden of 30 minutes.

Related forms

Who uses VA Form 10-0137?

  • The person making the advance directive

    The form is written for the person recording their own health care preferences, whom the witness section calls the patient. It asks them to initial the sections they complete and to sign the form.

  • A Health Care Agent and an alternate

    Part II names a person to make health care decisions if the patient can't decide anymore, and a second person in case the first isn't available. The form says the agent should be someone you trust, who knows you well and who is familiar with your values and beliefs.

  • Two witnesses

    The form says two people witness the signature. Neither may, to the witness' knowledge, be named as a beneficiary in the patient's estate, be appointed as health care agent in the advance directive, or be financially responsible for the patient's care.

  • Someone signing at the patient's direction

    If a physical impairment prevents initials, an X, a thumbprint or a stamp, the form says you can ask someone else who is with you to sign, place an X, thumbprint, or stamp on the form. That person can't also serve as a witness.

  • A notary public, if wanted

    Part V is optional. The form says it is valid in VA facilities without being notarized, and that you may need to have it notarized to be legally binding outside the VA health care setting.

The form names everyone who takes part in completing it.

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Questions about Form 10-0137

What is VA Form 10-0137 used for?

VA's page says to use it to give specific people permission to make health care decisions for you, and to let VA health care providers know your wishes for medical, mental health, long-term, and other types of care.

Do I need to fill out every section?

The form says you may complete some, none, or all sections of it. It also asks you to initial the sections you complete and to sign the form.

Does VA Form 10-0137 need to be notarized?

The form says it is valid in VA facilities without being notarized. It also says you may need to have it notarized to be legally binding outside the VA health care setting, and gives an optional Part V for that.

Who can be a witness?

The form says neither witness may, to the witness' knowledge, be named as a beneficiary in the patient's estate, be appointed as health care agent in the advance directive, or be financially responsible for the patient's care. A witness also can't be the person who signed at the patient's direction.

What if I can't sign because of a physical impairment?

The form says you can place an X, a thumbprint or a stamp instead of your initials and signature. If you can't do any of those, you can ask someone else who is with you to do it for you.

What can a Health Care Agent decide?

The form says the agent has the authority to make all health care decisions if you get too sick to decide, including admission to and discharge from a hospital, starting or stopping any treatment, and access to your health information and medical records.