Kaiser Health Care Directive – Fill Out and Use This PDF

If you wish to limit your health care agent's authority, specify what health care decisions you DO NOT want your agent to make. You may also name people who you DO NOT want to be involved in making health care decisions for you.

Under My primary (main) health care agent, fill in the Name and Relationship of the person you choose to make health care decisions for you if you are unable to make your own health care decisions. If you initial here, you want your health care agent to be able to make health care decisions for you immediately.

Then fill in the Mailing address, City, State, Zip code, Phone and Email.

Choose a first and second alternate agent to make health care decisions for you if your primary health care agent is not willing, able, or reasonably available.

This section is recommended but optional. If you do not wish to select alternate health care agents, go to the next page.

For the First alternate health care agent and the Second alternate health care agent, fill in Name, Relationship, Mailing address, City, State, Zip code, Phone and Email.

Sign AND choose ONE of Two Witnesses or Notary Public to make this document legally valid in the State of California.

Fill in My name printed and the Date, and sign on My signature line. If you use two witnesses, sign or acknowledge your signature when you are with your witnesses. If you use a Notary Public, do not sign unless you are with the Notary Public.

Check all that apply: Be physically active, Be socially active, Be able to live on my own, Work and/or volunteer, Spend time with friends and family, Make my own decisions, Engage with the community, Participate in my hobbies and/or passions, Engage in spirituality and/or religion or Other.

I DO NOT want any life-sustaining treatments: you do not want to start, and/or you would want to STOP life-sustaining treatments that have been previously started, and you would prefer to die naturally with a focus on your comfort.

I want a limited trial of life-sustaining treatments: you do not want to stay on the treatments if they are not helping you recover and there is little hope of you getting better.

I would want life-sustaining treatments to start or to continue, even if that means that you may remain on these treatments for the rest of your life.

I would want my health care agent to make the decision about the use of life-sustaining treatments for me based on my values and beliefs.

Choose one option for organ donation: Yes, No or I'm not sure to donate your organs, tissues, and parts upon your death.

Choose as many options as apply for the purposes of donating your organs: Transplant, Therapy, Research or Education.

If you leave this part blank, it's not a refusal to make a donation.

If you are physically unable to sign, any mark you make that you intend to be your signature is acceptable.

At least one of your witnesses cannot be related to you (by blood, marriage, or adoption) and cannot be entitled to any part of your estate.

Your primary and alternate health care agents can NOT sign as witnesses. The operator or employee of the place you're receiving care and/or your health care provider, or an employee of your health care provider, can NOT sign as a witness.

When you are with your witnesses, sign or acknowledge your signature. Note that this means your witnesses must sign and date on the same date or a later date than you. Witnesses will sign on page 14.

For Witness number one and Witness number two, fill in Name, Address, Signature and Date.

At least one of the witnesses must also sign the Additional Statement of Witnesses: I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this AHCD 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.

Do NOT sign this document unless you are with a Notary Public. Notary Public will sign on page 15.

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

The notary public fills in State of California, County of, (date), (Insert name and title of the officer), appeared (name(s) of signer(s) and Signature (seal).

If you are a patient in a skilled nursing facility, the patient advocate or ombudsman must sign the STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN.

If there is a dissolution, annulment, or termination of a marriage or domestic partnership with the person you've named as your health care agent, your health care agent designation will be revoked unless you complete the form again and name that person as your health care agent.

If you do not want CPR or other life-sustaining treatments now, please discuss with your doctor. You may benefit from completing a Physician Orders for Life Sustaining Treatment (POLST) form.

Give copies of your AHCD to your health care agent, to your doctor by uploading at kp.org OR bring to your local Kaiser Permanente Health Education Department, and keep a copy for yourself.

An Advance Health Care Directive does not tell emergency personnel what treatments you want during a medical emergency. This form does not authorize your agent to make financial or other business decisions for you.