California Advance Directive Form

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A California advance health care directive allows an individual to choose an agent to make medical decisions on their behalf and select end-of-life treatment options. An advance directive combines a medical power of attorney and a living will. It is recommended to be completed by elderly individuals and those seeking high-risk medical procedures.

The main purpose is to allow loved ones to make medical decisions on a person’s behalf and to outline their preferred life-saving treatment options. It is a combination of a medical power of attorney and a living will.

Advance Directive Includes

  • Part 1. Power of Attorney for Health Care
  • Part 2. Instructions for Health Care
  • Part 3. Donation of Organs, Tissues, and Parts at Death
  • Part 4. Primary Physician
  • Part 5. Signature
  • Part 6. Special Witness Requirement

Table of Contents

Laws

Statute – PROB § 4701

Signing Requirements (PROB § 4701) – Two (2) witnesses or a notary public.

State Definition (PROB § 4605) – “Advance health care directive” or “advance directive” means either an individual health care instruction or a power of attorney for health care.”

Registering

An individual can register an advance directive by completing the Registration Form (SFL-461), attaching a check for $10 (payable to the “Secretary of State”), and sending to:

Secretary of State
Special Filings Unit
P.O. Box 942870
Sacramento, CA
94277-2870

Versions (5)


 

AARP

Download: Adobe PDF

 

 

 


California Attorney General

Download: Adobe PDF

 

 

 


California Hospital Association

Download: English, Spanish (español)

 

 

 


 

UCLA

Download: Adobe PDF

 

 

 


 

UCSF Medical Center

Download: Adobe PDF

 


How to Write

Download: Adobe PDF

Part 1 Power Of Attorney For Health Care

(1.1) Designation Of Agent

(1) Name Of Agent. The California Health Care Agent that should represent your medical treatment preferences to Physicians in this state will need to be named in this directive to be effective. It should be noted that California Physicians will assume that you authorize the person you name as your Health Care Agent as being fully abreast with your medical treatment beliefs and can represent them in as accurate a manner as possible.

(2) Full Address. Attach your Health Care Agent’s mailing address to his or her identity. Make sure this is the address where your Agent can be located and can receive formal paperwork concerning your health care.

(3) Telephone Contact. Record every telephone number where your California Health Care Agent can be reached in a reliable way.

(4) First Alternate California Health Care Agent. As mentioned, California Physicians will assume your Agent is able to represent your medical directives however if your California Health Care Agent steps away from this role, cannot effectively act in concordance with your wishes, or is otherwise unable to represent you, then it will be useful to have a Successor to this role or an Alternate California Health Care Agent who can be authorized to represent you if any of these scenarios occur. This document will serve as an instrument to authorize your Alternate Agent to make medical decisions in your name as the replacement California Health Care Agent

(5) First Alternate Agent’s Address.

(6) First California Alternate’s Phone Number(s).

(7) Second Alternate California Health Care Agent. If your First Alternate Health Care Agent has been approached to replace your California Health Care Agent but denies this role or is unavailable, then it will be useful to have a Second California Alternate Health Care Agent pre-approved to assume the medical decision-making authority required to represent your treatment preferences. Name the Party you wish to approve as your California Health Care Agent should the First Alternate (and Original) Agent be unable to act for you.

(8) Second California Alternate Agent’s Address.

(9) Second California Alternate’s Phone Number(s).

(1.2) Agent’s Authority

(10) Principal Provisions And Instructions. The California Principal using this paperwork to appoint a Health Care Agent should consider if his or her Agent’s use of principal authority should be limited so that it excludes certain decisions or actions. You can limit your California Health Care Agent’s ability either by stating such restrictions plainly or by imposing specific instructions aimed at your Agent and California Medical personnel that will supersede your Agent’s authority.

(1.3) When Agent’s Authority Becomes Effective

(11) Declaring The Effective Date. The first calendar date when the California Health Care Agent will be allowed to represent the Principal’s medical determinations should be declared in this paperwork. These powers will automatically become effective when the California Principal can no longer communicate with Doctors regarding medical treatment, but this can be changed if the California Principal prefers that his or her Health Care Agent be able to represent his or her directives immediately upon the execution (signing) of this document.

(1.5) Agent’s Post Death Authority

(12) California Post Death Instructions. A set of directives regarding what the Principal wishes to be done with his or her remains after death can be included with this document. Such directives can include instructions on funerals, autopsies, cremation/burial, and organ donation and can be discussed by the California Principal directly to the space provided.

Part 2. Instructions For Health Care(2.1) End-Of-Life Decisions

(13) Artificially Prolonging Life. California Physicians will seek the Principal’s treatment decisions when faced with the choice of focusing medical goals on prolonging his or her life or to provide comfort and keep the Principal pain free (if possible). This directive can be accomplished by selecting Statement (A) or Statement (B).

(2.2) Relief From Pain

(14) Exceptions To Pain Management. The California Principal’s standing on the procedures and medication that Physicians in this state may need to use to control the Principal’s pain levels can be discussed through this document. Any limitations or restrictions the Principal wishes placed on pain management techniques and medications in the State of California should be stated in the appropriate area.

(2.3) Other Wishes

(15) Additional Advance Directive Instructions. While the general stance of aiming the California Patient (or Principal) care to focus on either longevity and prolonging life or providing comfort and keeping pain-free, there may be conditions, limitations, or specific treatment preferences the Principal wishes applied to the statement selected in Section 2.1. If so, use the area that has been included to present all such Principal directives.

Part 3. Donation Of Organs, Tissues, And Parts At Death (Optional)

(16) California Organ Donation. The California Principal can make a definitive statement regarding organ donations and other anatomical gifts with this directive. To authorize an anatomical gift made after death, the California Principal must select the checkbox corresponding to the authorization statement provided. This act will declare the California Principal’s intention to make organ donations and/or anatomical gifts in this state.

(17) Restrictions Upon Anatomical Gifts. A list of anatomical gift request goals that will be authorized for donation by the California Principal has been displayed. If any of these goals are not approved of by the Principal as being one for an anatomical donation to be made, then strike through it or delete it from this list. Additional instructions or conditions the California Principal wishes placed on all anatomical gift requests should be included to be considered part of these directives.

Part 4. Primary Physician

(4.1) Primary Physician

(18) Name Of Physician. It is strongly recommended that the identity of the California Principal’s Primary Physician is put at the disposal of future California Medical Staff reviewing the Principal’s directives. Record the full name of the Principal’s Primary Physician.

(19) Address And Phone. The complete address and phone number where the Principal’s Primary Physician can be reached should be dispensed. If the Primary Physician can only be reached through an Institution such as a Hospital, then make sure to include this Entity’s name as part of the address.

(20) Secondary Physician. An area where the California Principal’s second choice for Primary Physician has been supplied so that Reviewers may still obtain information about the Principal’s medical condition even if his or her Primary Physician is unavailable or cannot be reached.

(21) Second Physician Contact Information.

Part 5

(5.2) Signature

(22) Dated Signature. This document must be signed by the California Principal. The state will expect this signature to be verifiable thus, the California Principal should document the current date and provide his or her effective signature while a Witness or a Notary Public watches.

(23) Printed Name Of California Principal.

(24) Address. The legal address of the California Principal should be presented once he or she completes the signing.

(5.3) Statement Of Witnesses

(25) Witness Name And Address. The Statement Of Witnesses is placed as an acknowledgment of the Signature Witness’s qualifications as well as the authenticity of the signature the California Principal. Each Witness must self-identify with his or her printed name and address.

(26) Witness Signatures. Both Witnesses must sign their names and produce a record of the current date.

(5.4) Additional Statement Of Witness

(27) Witness Testimony. At least one Witness must be able to say that he or she is not related to the California Principal and not entitled to any part of the Principal’s estate upon death. To demonstrate this qualification, the Witness must sign his or her name. If needed, enough room has been provided for both Witnesses to provide such testimony.

Part 6. Special Witness Requirement

(28) Statement Of Patient Advocate Or Ombudsman. If the California Principal is a Resident in an advanced health care facility, then his or her Patient Advocate (or Patient Ombudsman) must provide a witness testimony that the signature made by the California Principal is authentic. A special statement for this Party has been provided where the Patient Advocate or Ombudsman must document the date of his or her signature and acknowledge the testimony by signature.

(29) Patient Advocate Or Ombudsman Information. The Patient Advocate or Ombudsman providing the signature testimony above must document his or her address and printed name as well.

Acknowledgment

(30) Notary Public. If the California Principal’s signature will be verified through notarization then the Notary Public attending the signing must take control of this paperwork upon the Principal’s signature to complete the Acknowledgment section.

 

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