Healthcare Power of Attorney

CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE

Power of Attorney for Health Care and Individual Health Care Instructions

(Cal. Prob. Code §§ 4700–4701)

IMPORTANT NOTICE TO PERSON EXECUTING THIS DOCUMENT

This is an important legal document. Before executing this document, you should know these important facts:

This document gives the person you designate as your agent the authority to make health care decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known.

Except as you otherwise specify in this document, this document gives your agent the power to consent to your physician not giving treatment or stopping treatment necessary to keep you alive.

Notwithstanding this document, you have every legal right to make your own health care decisions as long as you are able to give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped or withheld if you object at the time.

This document gives your agent authority to consent to, refuse, or withdraw consent for any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition, subject to the limitations you specify.

You may revoke this document at any time by notifying your agent or your treating physician, orally or in writing.

Unless you specify a shorter period in this document, this power of attorney will exist indefinitely from the date you execute this document and, if you are unable to make health care decisions for yourself at the time this power of attorney expires, the authority of your agent will continue in effect until the time you become able to make health care decisions for yourself.

You have the right to revoke the appointment of the agent and the right to revoke this entire document at any time and in any manner.

TABLE OF CONTENTS

1. Designation of Health Care Agent
2. Successor Agents
3. Agent Disqualifications and Eligibility
4. Decision-Making Standard
5. Agent's Powers and Authority
6. Mental Health Treatment Provisions
7. End-of-Life Treatment Instructions
8. POLST Coordination
9. Organ and Tissue Donation
10. Nomination of Conservator
11. Primary Physician Designation
12. HIPAA Authorization for Release of Protected Health Information
13. Agent Removal and Judicial Proceedings
14. Revocation and Amendment
15. General Provisions
16. Execution

1. DESIGNATION OF HEALTH CARE AGENT

(Cal. Prob. Code § 4701, Part 1)

1.1 Principal

I, [________________________________] ("Principal"), of

Address: [________________________________]

City: [________________________________] State: California ZIP: [________]

Date of Birth: [__/__/____]

hereby execute this Advance Health Care Directive pursuant to California Probate Code §§ 4700–4701.

1.2 Designation of Agent

I designate the following individual as my agent (attorney-in-fact) to make health care decisions for me:

Agent Name: [________________________________]

Address: [________________________________]

City: [________________________________] State: [________] ZIP: [________]

Phone: [________________________________]

Email: [________________________________]

Relationship to Principal: [________________________________]

1.3 Effective Date of Authority

My agent's authority to make health care decisions on my behalf shall become effective (select one):

☐ Upon Incapacity Only — When my attending physician determines in writing that I lack the capacity to make my own informed health care decisions (this is the default under Cal. Prob. Code § 4682).

☐ Immediately Upon Execution — Effective as of the date this document is signed, whether or not I have capacity. I may still make my own decisions as long as I am able.

2. SUCCESSOR AGENTS

2.1 First Successor Agent

If my primary agent named in Section 1.2 is unable or unwilling to serve, I designate:

Name: [________________________________]

Address: [________________________________]

City: [________________________________] State: [________] ZIP: [________]

Phone: [________________________________]

Relationship to Principal: [________________________________]

2.2 Second Successor Agent

If my first successor agent is also unable or unwilling to serve, I designate:

Name: [________________________________]

Address: [________________________________]

City: [________________________________] State: [________] ZIP: [________]

Phone: [________________________________]

Relationship to Principal: [________________________________]

2.3 Definitions of "Unable" and "Unwilling"

For purposes of this directive, an agent shall be deemed "unable" to serve if the agent:

(a) Has died;
(b) Has been determined to lack capacity by a licensed physician;
(c) Cannot be located or contacted after reasonable efforts within 48 hours;
(d) Is disqualified under Section 3 of this directive; or
(e) Is subject to a court order prohibiting the agent from serving.

An agent shall be deemed "unwilling" to serve if the agent:

(a) Provides written notice to the Principal (or, if the Principal lacks capacity, to the next successor agent or attending physician) declining to serve; or
(b) Fails to respond to contact attempts within 72 hours after being notified that a health care decision is required.

2.4 Successor Agent Authority

Each successor agent, upon assuming the role of agent, shall have all the same powers, duties, and authority as the originally designated agent under this directive.

3. AGENT DISQUALIFICATIONS AND ELIGIBILITY

(Cal. Prob. Code §§ 4659, 4673)

3.1 Persons Who May NOT Serve as Agent

The following persons are disqualified from serving as my health care agent:

(a) My supervising health care provider or an employee of my supervising health care provider, unless the person is related to me by blood, marriage, registered domestic partnership, or adoption;

(b) An operator of a community care facility serving me, or an employee of such operator, unless the person is related to me by blood, marriage, registered domestic partnership, or adoption;

(c) An operator of a residential care facility for the elderly serving me, or an employee of such operator, unless the person is related to me by blood, marriage, registered domestic partnership, or adoption.

3.2 Agent Eligibility

My agent must be:

(a) At least 18 years of age; and
(b) Of sound mind and able to fulfill the responsibilities of this appointment.

4. DECISION-MAKING STANDARD

(Cal. Prob. Code § 4684)

4.1 Primary Standard — Principal's Wishes

My agent shall make health care decisions in accordance with my individual health care instructions as stated in this directive and my other wishes to the extent known to my agent.

4.2 Secondary Standard — Best Interest

If my wishes regarding a particular health care decision are not known to my agent, my agent shall make the decision in accordance with my agent's determination of my best interest. In determining my best interest, my agent shall consider:

(a) My personal values, including religious, spiritual, and moral beliefs, to the extent known to my agent;
(b) My prior statements about health care preferences, quality of life, and acceptable medical outcomes;
(c) Information provided by my treating physicians regarding my medical condition, prognosis, and available treatment options;
(d) The burdens and benefits of proposed treatments, including pain, suffering, and the likelihood of recovery; and
(e) My known preferences regarding dignity, independence, and comfort.

4.3 Good-Faith Protection

My agent, when acting in good faith under this directive, shall not be subject to civil or criminal liability or professional discipline for making a health care decision consistent with this section (Cal. Prob. Code § 4740).

5. AGENT'S POWERS AND AUTHORITY

(Cal. Prob. Code §§ 4682–4690)

5.1 General Powers

Subject to any limitations stated in this directive, my agent has the authority to make all health care decisions for me, including but not limited to the power to:

(a) Consent to, refuse, or withdraw any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition;

(b) Select and discharge health care providers, including physicians, specialists, surgeons, dentists, mental health professionals, and other providers;

(c) Approve or refuse diagnostic tests, surgical procedures, and programs of medication;

(d) Authorize admission to or discharge from any hospital, skilled nursing facility, hospice, assisted-living facility, rehabilitation center, or other medical facility;

(e) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation;

(f) Access, review, use, and disclose my protected health information as provided in the HIPAA Authorization in Section 12;

(g) Contract for care on my behalf at any health care facility, including executing any admission, consent, waiver, or release forms;

(h) Request and consent to pain management, comfort care, and palliative care;

(i) Apply for benefits on my behalf, including Medicare, Medi-Cal, veterans' benefits, disability benefits, and private insurance benefits relating to health care;

(j) Hire and direct home health aides, caregivers, and other support personnel; and

(k) Take any other action necessary to carry out the health care decisions authorized under this directive, including executing waivers, releases, and other documents.

5.2 Limitations on Agent's Authority

My agent's authority is subject to the following specific limitations:

[________________________________]

[________________________________]

[________________________________]

☐ I have no additional limitations beyond those required by law.

5.3 Statutory Limitations

Regardless of any other provision in this directive, my agent may not:

(a) Consent to my commitment to or placement in a mental health treatment facility (Cal. Prob. Code § 4652);

(b) Consent to convulsive treatment (electroconvulsive therapy) on my behalf, unless I have specifically authorized this in Section 6 of this directive (Cal. Prob. Code § 4652);

(c) Consent to psychosurgery on my behalf (Cal. Prob. Code § 4652);

(d) Consent to sterilization on my behalf (Cal. Prob. Code § 4652);

(e) Consent to abortion on my behalf (Cal. Prob. Code § 4652); or

(f) Make a health care decision while I am capable of making my own decisions and object to the decision (Cal. Prob. Code § 4689).

6. MENTAL HEALTH TREATMENT PROVISIONS

(Cal. Prob. Code § 4652; Welf. & Inst. Code § 5000 et seq.)

6.1 General Mental Health Treatment Authority

I grant my agent the following authority regarding mental health treatment (check all that apply):

☐ My agent may consent to or refuse outpatient mental health treatment, including therapy and counseling.

☐ My agent may consent to or refuse psychotropic medications prescribed for mental health conditions, including antidepressants, antipsychotic medications, mood stabilizers, and anti-anxiety medications.

☐ My agent may consent to voluntary admission to a mental health treatment program or facility on my behalf. (Note: This does NOT authorize involuntary commitment, which requires a separate legal proceeding under the Lanterman-Petris-Short Act, Welf. & Inst. Code § 5000 et seq.)

☐ My agent may consent to or refuse substance abuse treatment programs on my behalf.

6.2 Electroconvulsive Therapy (ECT)

☐ I specifically authorize my agent to consent to electroconvulsive therapy (ECT) on my behalf if my treating psychiatrist determines it is medically appropriate.

☐ I do not authorize my agent to consent to electroconvulsive therapy on my behalf.

6.3 Mental Health Treatment Preferences

If I require mental health treatment and am unable to make decisions for myself, I have the following preferences:

[________________________________]

[________________________________]

[________________________________]

6.4 Limitations Not Waivable

The following limitations apply regardless of any elections above:

(a) My agent may never consent to my involuntary commitment to or placement in a mental health treatment facility (Cal. Prob. Code § 4652);

(b) My agent may never consent to psychosurgery on my behalf (Cal. Prob. Code § 4652); and

(c) No treatment may be administered to me over my contemporaneous objection if I am capable of communicating that objection (Cal. Prob. Code § 4689).

7. END-OF-LIFE TREATMENT INSTRUCTIONS

(Cal. Prob. Code §§ 4653–4660, 4701)

7.1 General Statement

If I am diagnosed with a terminal condition (an incurable and irreversible condition that, without the administration of life-sustaining treatment, will result in death within a relatively short time) or am in a permanent unconscious condition (a condition in which thought, sensation, purposeful behavior, and awareness of self and environment are absent), I direct the following:

7.2 Life-Sustaining Treatment

(Select one)

☐ I want life-sustaining treatment to be provided.

☐ I do not want life-sustaining treatment. I direct that treatment be limited to comfort care and palliative measures only.

☐ I want my agent to decide whether to provide, withhold, or withdraw life-sustaining treatment based on my known wishes and values, or if unknown, my best interest.

7.3 Specific Treatment Instructions

I direct the following regarding specific categories of treatment (check the appropriate box for each category):

Cardiopulmonary Resuscitation (CPR)

☐ I want CPR attempted if my heart stops or I stop breathing.
☐ I do not want CPR attempted (DNR).
☐ I want my agent to decide.

Mechanical Ventilation (Breathing Machine)

☐ I want mechanical ventilation if I cannot breathe on my own.
☐ I do not want mechanical ventilation.
☐ I want my agent to decide.

Artificial Nutrition (Tube Feeding)

☐ I want tube feeding if I cannot eat or drink.
☐ I do not want tube feeding.
☐ I want my agent to decide.

Artificial Hydration (IV Fluids)

☐ I want IV fluids if I cannot drink.
☐ I do not want IV fluids.
☐ I want my agent to decide.

Dialysis (Kidney Machine)

☐ I want dialysis if my kidneys fail.
☐ I do not want dialysis.
☐ I want my agent to decide.

Antibiotics

☐ I want antibiotics for life-threatening infections.
☐ I do not want antibiotics for life-threatening infections.
☐ I want my agent to decide.

Blood Transfusions

☐ I want blood transfusions if needed.
☐ I do not want blood transfusions.
☐ I want my agent to decide.

7.4 Comfort Care and Pain Management

Regardless of any other instructions in this directive, I always want comfort care provided, including:

(a) Medication and treatment to relieve pain and suffering, even if such medication may hasten my death;
(b) Hygiene and personal care;
(c) Measures to keep me warm, dry, and as comfortable as possible; and
(d) Emotional and spiritual support.

☐ I do not want pain medication that would make me unconscious if other alternatives exist.
☐ I authorize my agent to consent to palliative sedation as a last resort if pain cannot otherwise be controlled.

7.5 Pregnancy Provision

If I am pregnant at the time a health care decision must be made under this section, my instructions regarding life-sustaining treatment are (select one):

☐ To be followed regardless of my pregnancy status.
☐ To be suspended during my pregnancy if there is a possibility of a live birth.
☐ I want my agent to decide based on the specific circumstances.

7.6 Prohibition on Euthanasia

Nothing in this directive shall be construed to condone, authorize, or approve mercy killing, assisted suicide, or euthanasia, or to permit any affirmative or deliberate act to end life other than the withholding or withdrawal of health care so as to permit the natural process of dying (Cal. Prob. Code § 4653).

7.7 Additional End-of-Life Instructions

[________________________________]

[________________________________]

[________________________________]

8. POLST COORDINATION

(Cal. Prob. Code §§ 4780-4786; Cal. Health & Safety Code § 1862 et seq.)

8.1 Relationship to POLST

This advance health care directive and any POLST form completed on my behalf are complementary documents. If a conflict exists between this directive and a POLST:

☐ This directive controls. Any POLST should be revised to be consistent with this directive.

☐ The most recently executed document controls, whether it is this directive or a POLST.

☐ I want my agent to decide which document controls in the event of a conflict.

8.2 Agent Authority Regarding POLST

I authorize my agent to:

(a) Request, review, and participate in the completion of a POLST form with my treating physician, nurse practitioner, or physician assistant;

(b) Sign a POLST form on my behalf if I lack capacity to sign it myself;

(c) Request revisions to an existing POLST to ensure consistency with this directive and my known wishes; and

(d) Revoke a POLST on my behalf if it no longer reflects my wishes.

8.3 Current POLST Status

☐ I have a POLST form on file. Location: [________________________________]

☐ I do not currently have a POLST form. I would like my agent to discuss the need for a POLST with my physician if my health condition warrants one.

9. ORGAN AND TISSUE DONATION

(Cal. Health & Safety Code §§ 7150–7151.40, Uniform Anatomical Gift Act)

9.1 Anatomical Gift Elections

Upon my death (select one):

☐ I donate all organs and tissues for transplantation, therapy, research, or education.

☐ I donate only the following organs or tissues:

[________________________________]

☐ I donate my organs and tissues only for the following purposes (check all that apply):

☐ Transplantation
☐ Therapy
☐ Research
☐ Education

☐ I do not wish to donate any organs or tissues.

9.2 Agent Authority for Donation Decisions

If I have not indicated a preference above, or if circumstances arise not covered by my election:

☐ I authorize my agent to make organ and tissue donation decisions on my behalf, consistent with my known values and wishes.

☐ I do not authorize my agent to make organ and tissue donation decisions on my behalf.

9.3 Restrictions on Physician Participation

The physician who attends me at the time of death, and the physician who determines the time of my death, may not participate in the procedures for removing or transplanting my organs or tissues (Cal. Health & Safety Code § 7151.15).

10. NOMINATION OF CONSERVATOR

(Cal. Prob. Code §§ 1810, 4701)

If it becomes necessary for a court to appoint a conservator of my person, I nominate the following individual(s) in the order listed:

First Nominee: [________________________________] (my agent)

Second Nominee: [________________________________] (my first successor agent)

Third Nominee: [________________________________] (my second successor agent)

I request that the court give substantial weight to this nomination in accordance with Cal. Prob. Code § 1810.

11. PRIMARY PHYSICIAN DESIGNATION

(Cal. Prob. Code § 4701)

11.1 Primary Physician

I designate the following as my primary physician:

Name: [________________________________]

Address: [________________________________]

Phone: [________________________________]

11.2 Alternate Physician

If my primary physician is not available, willing, or able to serve, I designate:

Name: [________________________________]

Address: [________________________________]

Phone: [________________________________]

12. HIPAA AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

(45 C.F.R. § 164.508)

12.1 Authorization

I, [________________________________] (Principal), authorize each of my health care providers, health plans, and any other Covered Entity or Business Associate as defined by HIPAA to disclose my protected health information ("PHI") to my agent and any successor agents named in this directive.

12.2 Scope of Information Authorized for Disclosure

This authorization applies to the following categories of PHI (check all that apply):

☐ All protected health information, without limitation, including but not limited to all medical records, diagnoses, treatment plans, test results, billing records, prescription history, and communications with health care providers.

☐ Only the following categories of PHI:

☐ Medical records and history
☐ Diagnoses and prognoses
☐ Treatment plans and options
☐ Laboratory and imaging results
☐ Prescription and medication records
☐ Billing and insurance records
☐ Mental health treatment records
☐ Substance abuse treatment records (42 C.F.R. Part 2 applies — additional consent may be required)
☐ HIV/AIDS-related records
☐ Genetic information
☐ Other: [________________________________]

12.3 Persons Authorized to Receive PHI

The following persons are authorized to receive my PHI under this authorization:

(a) My agent named in Section 1.2;
(b) My successor agents named in Section 2;
(c) Other: [________________________________]

12.4 Purpose of Disclosure

The purpose of this authorization is to enable my agent to make informed health care decisions on my behalf and to carry out the duties assigned under this directive.

12.5 Expiration

This authorization shall expire upon the earliest of:

(a) My written revocation delivered to the Covered Entity;
(b) Revocation of this advance health care directive; or
(c) My death, except that this authorization shall survive my death to the extent necessary for my agent to carry out the duties assigned under this directive, including decisions regarding organ donation, autopsy, and disposition of remains.

12.6 Right to Revoke

I understand that I have the right to revoke this authorization at any time by providing written notice to the Covered Entity, except to the extent that action has already been taken in reliance on this authorization. I understand that revocation of this authorization may impair my agent's ability to make health care decisions on my behalf.

12.7 Redisclosure Notice

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by my agent or the recipient and may no longer be protected by federal privacy regulations.

12.8 No Conditioning of Treatment

I understand that my health care providers may not condition treatment, payment, enrollment, or eligibility for benefits on the signing of this authorization.

12.9 Photocopy Validity

A photocopy, facsimile, or electronically transmitted copy of this authorization shall be as valid as the original.

13. AGENT REMOVAL AND JUDICIAL PROCEEDINGS

(Cal. Prob. Code §§ 4750–4766)

13.1 Grounds for Agent Removal

My agent's authority may be terminated by court order under Cal. Prob. Code § 4766 upon a finding that:

(a) My agent has made a health care decision that authorized something illegal; or

(b) My agent has violated, failed to perform, or is unfit to perform the duty to act consistent with my desires (or, if my desires are unknown, is acting in a manner clearly contrary to my best interest), and I lack the capacity to execute a new directive or revoke this one.

13.2 Petition Authority

Any interested person may file a petition in the Superior Court of the county in which I reside for any of the following purposes (Cal. Prob. Code § 4766):

(a) Determining whether I have capacity to make health care decisions;

(b) Determining whether this directive is in effect or has terminated;

(c) Determining whether my agent's acts or proposed acts are consistent with my wishes or, if unknown, my best interest;

(d) Declaring that my agent's authority is terminated;

(e) Compelling a third person to honor this directive or my agent's authority; or

(f) Approving the sale of my separate property by a spouse or registered domestic partner for my health care needs.

13.3 Automatic Succession

If my agent's authority is terminated by court order or for any other reason, the next successor agent listed in Section 2 shall automatically assume authority, subject to the eligibility requirements of Section 3.

14. REVOCATION AND AMENDMENT

(Cal. Prob. Code §§ 4695–4698)

14.1 Methods of Revocation

I may revoke this directive at any time by any of the following methods:

(a) Executing a new advance health care directive (a later directive revokes an earlier one to the extent of any conflict);

(b) A signed written statement expressing my intent to revoke;

(c) Physically canceling or destroying this document or directing another person to do so in my presence;

(d) An oral statement to my attending physician expressing my intent to revoke, which shall be documented in my medical record; or

(e) Any other act that demonstrates a specific intent to revoke.

14.2 Partial Revocation

I may revoke this directive in whole or in part. Revocation of the appointment of my agent does not revoke my individual health care instructions, and revocation of my individual health care instructions does not revoke the appointment of my agent, unless I expressly state otherwise.

14.3 Amendment

I may amend this directive at any time by executing a written amendment with the same formalities required for execution of the original directive.

14.4 Effect of Divorce or Dissolution

Unless I expressly provide otherwise, if my agent is my spouse or registered domestic partner, and our marriage or domestic partnership is subsequently dissolved or annulled, the designation of that person as my agent is automatically revoked (Cal. Prob. Code § 4697).

15. GENERAL PROVISIONS

15.1 Reliance by Third Parties

No health care provider, health plan, or other person who in good faith accepts this directive and acts in accordance with its terms shall be subject to civil or criminal liability or professional discipline for such actions (Cal. Prob. Code § 4740). A photocopy, facsimile, or electronically transmitted copy of this directive has the same effect as the original (Cal. Prob. Code § 4678).

15.2 Severability

If any provision of this directive is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

15.3 No Duty to Investigate

No person to whom a copy of this directive is presented shall have a duty to investigate the validity of the directive, the authority of the agent, or whether any event of revocation has occurred, provided that the person acts in good faith.

15.4 Governing Law

This directive shall be governed by the laws of the State of California, including the Health Care Decisions Law (Cal. Prob. Code §§ 4600–4806).

15.5 Agent Compensation

☐ My agent shall serve without compensation, but shall be entitled to reimbursement for reasonable out-of-pocket expenses incurred in performing duties under this directive.

☐ My agent shall receive reasonable compensation in the amount of [________________________________] for services performed under this directive.

15.6 Agent's Duty to Notify

My agent shall promptly notify my successor agent(s), attending physician, and family members if my agent becomes unable or unwilling to continue serving.

15.7 Prior Directives

This directive supersedes all prior advance health care directives I have executed, to the extent of any conflict. I direct my agent to retrieve and destroy all prior advance health care directives in the possession of health care providers, family members, and others to whom copies were distributed.

16. EXECUTION

(Cal. Prob. Code §§ 4673–4675)

16.1 Principal's Signature

I sign my name to this Advance Health Care Directive on this [____] day of [________________________________], 20[____], at [________________________________], California.

I declare under penalty of perjury under the laws of the State of California that I am at least 18 years old, of sound mind, and executing this directive voluntarily, free from duress, fraud, or undue influence.

______________________________________________
Signature of Principal

______________________________________________
Printed Name of Principal

COMPLETE EITHER OPTION A OR OPTION B — NOT BOTH

16.2 OPTION A — Notary Acknowledgment

State of California
County of [________________________________]

On [__/__/____], before me, [________________________________], a notary public in and for said state, personally appeared [________________________________], who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

______________________________________________
Notary Public Signature

(My Commission Expires: __________________)

[NOTARY SEAL]

16.3 OPTION B — Witness Attestation

DECLARATION OF WITNESSES

We declare under penalty of perjury under the laws of the State of California that:

1. The Principal is personally known to us (or proved identity to us on the basis of convincing evidence);
2. The Principal signed or acknowledged this directive in our presence;
3. The Principal appears to be of sound mind and under no duress, fraud, or undue influence;
4. Neither of us is the person appointed as agent by this directive;
5. Neither of us is the Principal's health care provider, or an employee of the Principal's health care provider;
6. Neither of us is the operator or an employee of a community care facility or a residential care facility for the elderly in which the Principal resides; and
7. At least one of us is not related to the Principal by blood, marriage, or adoption, and is not entitled to any portion of the Principal's estate upon death under a will or by operation of law.

Witness No. 1:

______________________________________________
Signature                          Date: __/__/____

______________________________________________
Printed Name

______________________________________________
Address

______________________________________________
City, State, ZIP

Witness No. 2:

______________________________________________
Signature                          Date: __/__/____

______________________________________________
Printed Name

______________________________________________
Address

______________________________________________
City, State, ZIP

16.4 SKILLED NURSING FACILITY REQUIREMENT

(Cal. Prob. Code § 4675)

☐ Check here if the Principal is a patient in a skilled nursing facility.

If the Principal is a patient in a skilled nursing facility, a patient advocate or ombudsman designated by the State Department of Aging must sign below as a witness. This requirement applies in addition to notarization or the two witness signatures above.

I, the undersigned patient advocate or ombudsman, certify that I am serving as a patient advocate or ombudsman as designated by the State Department of Aging. I have observed the Principal sign this directive (or acknowledge the signature), and I believe the Principal is of sound mind and is executing this directive voluntarily.

______________________________________________
Signature of Patient Advocate or Ombudsman

______________________________________________
Printed Name

______________________________________________
Title / Designation

Date: __/__/____

16.5 OPTIONAL — Agent's Acceptance of Appointment

I, [________________________________], have read this Advance Health Care Directive. I understand and accept the responsibilities of serving as health care agent for [________________________________] (Principal). I agree to act in accordance with the Principal's wishes as expressed in this directive and, where the Principal's wishes are unknown, in the Principal's best interest.

______________________________________________
Signature of Agent                  Date: __/__/____

______________________________________________
Printed Name of Agent

Successor Agent Acceptance (Optional):

I, [________________________________], accept the appointment as successor health care agent and agree to serve if called upon under the terms of this directive.

______________________________________________
Signature of Successor Agent        Date: __/__/____

______________________________________________
Printed Name of Successor Agent

SOURCES AND REFERENCES

• California Health Care Decisions Law — Cal. Prob. Code §§ 4600–4806
  https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=PROB&division=4.7.

• Statutory Advance Health Care Directive Form — Cal. Prob. Code §§ 4700–4701
  https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=PROB&division=4.7.&part=2.&chapter=2.

• Execution Requirements — Cal. Prob. Code §§ 4673–4675
  https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=4673.&lawCode=PROB

• Agent Decision-Making Standard — Cal. Prob. Code § 4684
  https://law.justia.com/codes/california/code-prob/division-4-7/part-2/chapter-1/article-2/section-4684/

• Mental Health Treatment Limitations — Cal. Prob. Code § 4652
  https://codes.findlaw.com/ca/probate-code/prob-sect-4652.html

• Agent Removal / Judicial Proceedings — Cal. Prob. Code § 4766
  https://law.justia.com/codes/california/2022/code-prob/division-4-7/part-3/chapter-3/section-4766/

• POLST (Physician Orders for Life-Sustaining Treatment) — Cal. Prob. Code §§ 4780-4786; Cal. Health & Safety Code § 1862 et seq. (POLST eRegistry)
  https://capolst.org/

• Uniform Anatomical Gift Act — Cal. Health & Safety Code §§ 7150–7151.40
  https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=HSC&division=7.&part=1.&chapter=3.5.

• HIPAA Privacy Rule — Authorization Requirements — 45 C.F.R. § 164.508
  https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.508

• UCLA Law Library — California Advance Directives Guide
  https://libguides.law.ucla.edu/c.php?g=183395&p=1208714

This template is provided by ezel.ai for informational purposes only and does not constitute legal advice. An advance health care directive is a critical legal document that directly affects medical care at the most vulnerable times. Have this document reviewed and customized by a qualified California attorney before execution. Statutory citations are current as of the date shown above; always verify that no legislative changes have occurred before relying on this template.