(1) Any competent person aged eighteen (18) years or older may execute an advance care planning document (ACPD). Such document must contain the mandatory elements set forth in this section. Any provisions of an ACPD that are left blank by a person executing the document shall be deemed intentional and shall not invalidate the document. The department of health and welfare may create and promulgate an optional form for the ACPD. Such form is not mandatory. To be considered a valid ACPD, a document must include:
(a)  The person’s name, date of birth, telephone number, and mailing address;
(b)  The signature of the person for whom the ACPD is created or the authorized agent of such person; and
(c)  The date on which the document was signed.
(2)  An ACPD may but is not required to include the following:
(a)  The electronic mail address of the person executing the ACPD;
(b)  Nomination of one (1) or more persons to act as a health care agent;
(c)  The name, mailing address, electronic mail address, and telephone number of any person nominated as a health care agent, as well as such person’s relationship to the person executing the ACPD;
(d)  Resuscitation instructions;
(e)  Instructions regarding pregnancy;
(g)  Instructions for the release of information protected by the federal health insurance portability and accountability act;
(h)  Instructions for end-of-life care;
(i)  A description of treatment objectives;
(j)  The names and contact information of witnesses to the execution of the ACPD; and
(k)  Notarization.