Ca Advance Healthcare Directive Form PDF Details

Navigating the complexities of healthcare decisions can be daunting, especially when dealing with serious illness or incapacity. The California Advance Healthcare Directive form serves as a beacon of control and peace of mind in such turbulent times. Crafted under the guidelines of the California Probate Code sections 4700-4701, this document empowers individuals to outline their healthcare preferences and appoint a trusted agent to make decisions on their behalf if they're unable to do so themselves. It's a comprehensive tool that addresses several critical aspects: from designating a decision-maker for your healthcare and setting out specific healthcare wishes, to making decisions about organ donation and choosing a primary physician. Moreover, Part 1 of the form acts as a power of attorney for healthcare, allowing you to name someone to make medical decisions for you, potentially even before incapacity hits. Part 2 gives room to specify your healthcare directives, which can guide or altogether direct treatments according to your wishes. Sections on organ donation and the designation of a primary physician offer additional personalization of your healthcare trajectory. When completed, this legal document must be signed by either two qualified witnesses or acknowledged before a notary public. It becomes a critical piece of your healthcare puzzle, providing clear directives to healthcare providers and ensuring that your preferences are respected, no matter what the future holds.

QuestionAnswer
Form NameCa Advance Healthcare Directive Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other nameshealth care form, california advance health care directive, california advance directive, advance health care directive california

Form Preview Example

ADVANCE HEALTH CARE DIRECTIVE FORM

CALIFORNIA PROBATE CODE SECTION 4700-4701

PAGE 1 of 5

4700. The form provided in Section 4701 may, but need not, be used to create an advance health care directive. The other sections of this division govern the effect of the form or any other writing used to create an advance health care directive. An individual may complete or modify all or any part of the form in Section 4701.

4701. The statutory advance health care directive form is as follows:

ADVANCE HEALTH CARE DIRECTIVE (California Probate Section 4701) Explanation

You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.

Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able, or reasonably available to make decisions for you. (Your agent may not be an operator or employee of a community care facility or a residential care facility where you are receiving care, or your supervising health care provider or employee of the health care institution where you are receiving care, unless your agent is related to your or is a coworker.)

Unless the form you sign limits the authority of your agent, your agent may make all health care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to:

(a)Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a physical or mental condition.

(b)Select or discharge health care providers and institutions.

(c)Approve or disapprove diagnostic tests, surgical procedures,and programs of medication.

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

(e)Make anatomical gifts, authorize an autopsy, and direct disposition of remains.

Part 2 of this form lets you give specific instructions about any aspect of your health care, whether or not you appoint an agent.Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive,as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out Part 2 of this form.

Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death. Part 4 of this form lets you designate a physician to have primary responsibility for your health care.

After completing this form, sign and date the form at the end.The form must be signed by two qualified witnesses or acknowledged before a notary public. Give a copy of the signed and completed form to your physician, to any other health care providers you may have,to any health care institution at which you are receiving care, and to any health care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility.

You have the right to revoke this advance health care directive or replace this form at any time.

PART 1

POWER OF ATTORNEY FOR HEALTH CARE

(1.1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me:

(name of individual you choose as agent)

(address)

(city)

(state)

(ZIP Code)

(home phone)

(work phone)

ADVANCE HEALTH CARE DIRECTIVE FORM

PAGE 2 of 5

OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health care decision for me, I designate as my first alternate agent:

(name of individual you choose as first alternate agent)

(address)

(city)

(state)

(ZIP Code)

 

 

 

 

 

 

(home phone)

(work phone)

 

 

OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate agent:

(name of individual you choose as second alternate agent)

(address)

(city)

(state)

(ZIP Code)

 

 

 

 

 

 

(home phone)

(work phone)

 

 

(1.2) AGENT'S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:

(Add additional sheets if needed.)

(1.3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box.

If I mark this box ( ), my agent's authority to make health care decisions for me takes effect immediately.

(1.4.) AGENT'S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

(1.5) AGENT'S POSTDEATH AUTHORITY: My agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains, except as I state here or in Part 3 of this form:

(Add additional sheets if needed.)

ADVANCE HEALTH CARE DIRECTIVE FORM

PAGE 3 of 5

(1.6) NOMINATION OF CONSERVATOR: If a conservator of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not willing, able, or reasonably available to act as conservator, I nominate the alternate agents whom I have named, in the order designated.

PART 2

INSTRUCTIONS FOR HEALTH CARE

If you fill out this part of the form, you may strike any wording you do not want.

(2.1) END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:

(a) Choice Not to Prolong Life

I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR

(b) Choice to Prolong Life

I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

(2.2) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death:

(Add additional sheets if needed.)

(2.3) OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that:

(Add additional sheets if needed.)

PART 3

DONATION OF ORGANS AT DEATH

(OPTIONAL)

(3.1) Upon my death (mark applicable box):

(a) I give any needed organs, tissues, or parts, OR

(b) I give the following organs, tissues, or parts only.

(c) My gift is for the following purposes (strike any of the following you do not want):

(1)Transplant

(2)Therapy

(3)Research

(4)Education

ADVANCE HEALTH CARE DIRECTIVE FORM

PAGE 4 of 5

PART 4

PRIMARY PHYSICIAN

(OPTIONAL)

(4.1) I designate the following physician as my primary physician:

(name of physician)

(address)

(city)

(state)

(ZIP Code)

(phone)

OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I designate the following physician as my primary physician:

(name of physician)

(address)

(city)

(state)

(ZIP Code)

(phone)

PART 5

(5.1) EFFECT OF COPY: A copy of this form has the same effect as the original.

(5.2) SIGNATURE: Sign and date the form here:

(print your name)

(sign your name)

 

 

(date)

 

 

 

 

 

 

 

 

 

 

 

(address)

(city)

(state)

(ZIP Code)

(5.3) STATEMENT OF WITNESSES: I declare under penalty of perjury under the laws of California (1) that the individual who signed or acknowledged this advance health care directive is personally known to me, or that the individual's identity was proven to me by convincing evidence (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a person appointed as agent by this advance directive, and (5) that I am not the individual's health care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly.

First witness

Second witness

(print name)

 

(print name)

ADVANCE HEALTH CARE DIRECTIVE FORM

PAGE 5 of 5

 

(address)

 

 

(address)

 

 

 

 

 

(city)

(state)

 

(city)

(state)

(signature of witness)

 

(signature of witness)

 

 

 

(date)

 

(DATE)

(5.4) ADDITIONAL STATEMENT OF WITNESSES: At least one of the above witnesses must also sign the following declaration:

I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of law.

(signature of witness)

(signature of witness)

PART 6

SPECIAL WITNESS REQUIREMENT

(6.1) The following statement is required only if you are a patient in a skilled nursing facility--a health care facility that provides the following basic services: skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. The patient advocate or ombudsman must sign the following statement:

STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN

I declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and that I am serving as a witness as required by Section 4675 of the Probate Code.

(print your name)

(sign your name)

 

 

(date)

 

 

 

 

 

 

 

 

 

 

 

(address)

(city)

(state)

(ZIP Code)

How to Edit Ca Advance Healthcare Directive Form Online for Free

You could work with california advance health directive form pdf easily by using our PDFinity® online tool. Our expert team is constantly endeavoring to develop the editor and make it even easier for people with its many functions. Unlock an constantly progressive experience today - check out and find new opportunities as you go! In case you are seeking to begin, this is what you will need to do:

Step 1: Click the "Get Form" button above on this page to access our editor.

Step 2: This tool offers the ability to work with your PDF form in many different ways. Transform it by writing any text, correct original content, and put in a signature - all close at hand!

Filling out this form needs care for details. Make certain each and every blank field is filled in correctly.

1. Before anything else, while filling in the california advance health directive form pdf, start out with the form section that includes the next blank fields:

Simple tips to fill out california advance health care directive 2021 pdf step 1

2. Right after this selection of fields is filled out, proceed to enter the suitable details in these - OPTIONAL If I revoke my agents, name of individual you choose as, address, home phone, city, state, ZIP Code, work phone, OPTIONAL If I revoke the authority, name of individual you choose as, address, home phone, city, state, and ZIP Code.

Step no. 2 of filling in california advance health care directive 2021 pdf

People who use this document frequently make mistakes while filling out state in this section. Ensure that you double-check whatever you type in right here.

3. The next part is going to be easy - complete all the form fields in AGENTS AUTHORITY My agent is, Add additional sheets if needed, WHEN AGENTS AUTHORITY BECOMES, If I mark this box my agents, AGENTS OBLIGATION My agent shall, and AGENTS POSTDEATH AUTHORITY My to complete this process.

Filling out segment 3 of california advance health care directive 2021 pdf

4. This next section requires some additional information. Ensure you complete all the necessary fields - a Choice Not to Prolong Life, I do not want my life to be, within a relatively short time I, b Choice to Prolong Life, I want my life to be prolonged as, RELIEF FROM PAIN Except as I, Add additional sheets if needed, OTHER WISHES If you do not agree, and Add additional sheets if needed - to proceed further in your process!

How you can fill in california advance health care directive 2021 pdf part 4

5. To conclude your form, this particular area has a couple of additional blanks. Filling out a I give any needed organs tissues, b I give the following organs, c My gift is for the following, and Transplant Therapy Research will conclude the process and you'll definitely be done in a flash!

Filling in segment 5 in california advance health care directive 2021 pdf

Step 3: As soon as you have reread the details you filled in, just click "Done" to complete your form. Create a 7-day free trial subscription with us and obtain instant access to california advance health directive form pdf - downloadable, emailable, and editable in your personal cabinet. FormsPal ensures your data privacy by having a protected method that never records or shares any sort of personal data typed in. Feel safe knowing your documents are kept confidential every time you work with our service!