Join DocuBank - emergency access living will registry,health care directive registry, state registry

Complete the enrollment form below. Next, print it out and sign it. (Alternatively, you can print the form and then fill it out by hand.)

Send the following materials to DocuBank^Ž:

The completed enrollment form (signed).
A signed copy of your health care documents (living will, health care power of attorney, organ donation form). (Note: We do not require original documents.)
Your payment (check for $45 for one year/$145 for five years, or credit card information).

Mail the enrollment materials to:
	DocuBank^Ž P. O. Box 325 Narberth, PA 19072-0325

A. Personal Information: Please print clearly

Prefix

First Name

Middle Initial

Last Name

Suffix

Mailing Address

Mailing Address Line 2

City

State

Zip Code

--
Home Phone

--
Work Phone Ext:

Email Address

Date of Birth (mm/dd/yyyy)

Permanent medical condtions to appear on the front of the card:
Allergies	Medical Conditions
Notes:

B. Emergency Contacts: (Optional) The names and phone numbers of your emergency contacts and physician will be provided to hospital staff when your documents are requested. If your living will, health care power of attorney, or other advance directive names people to make decisions for you, please list up to three of them here in the same order. If no one is listed in your documents, you may choose up to three people as emergency contacts and list them here.
1. Name (First)	(Last)	Relationship
-- Home Phone	-- Work Phone Ext:
-- Cell Phone
Email Address
2. Name (First)	(Last)	Relationship
-- Home Phone	-- Work Phone Ext:
-- Cell Phone
Email Address
3. Name (First)	(Last)	Relationship
-- Home Phone	-- Work Phone Ext:
-- Cell Phone
Email Address
Primary Care Physician:
Dr. Name (First)	(Last)
-- Work Phone Ext:

C. Service Selection: Please select one option
Individual Membership:	One Year, $45
	Five Years, $145
Please note: Each member must complete a separate enrollment form.

D. Method of Payment
Check or Money Order (payable to Advance Choice/DocuBank^Ž)
MasterCard Visa AMEX Discover
Card Number: Exp. Date: Month: Year:
Please renew my membership when due and bill my credit card for membership length: One Year Five Years

E. Membership Source: Name of professional organization or individual referring you (if applicable).*
Source Name	-- Phone Ext:

If you are enrolling without the help of a DocuBank attorney or advisor, and would like to find one in your area, visit our Attorney/Advisor Finde*r. We’ll contact you with the names of professionals who are using the service for their clients.
F. Member Statement:
I have completed an advance directive document (e.g., living will, health care power of attorney, other advance directive, and/or organ donation information) of my own free will and have chosen to enroll in DocuBank to help make my document(s) available when needed. To ensure immediate access, I request that my document(s) be faxed to anyone who provides the member number and access code on my card. I will notify DocuBank of changes to my information or to the revocation or replacement of my document(s). I understand that DocuBank does not provide legal advice, and that I may cancel this service at any time by written request to DocuBank.
Signature	Date
Remember to sign this form and enclose a clear copy of your document(s) with this form and your payment.

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