Free California Medical Power of Attorney Form

Need a different document? Browse all our California power of attorney forms, or read about the medical power of attorney form in general.

What Is a California Medical Power of Attorney?

A medical power of attorney, also called a healthcare power of attorney, lets you name an agent to make health care decisions if you are unable to make them yourself. You, the principal, name the agent. You may also hear this person called a health care proxy.

California state law sets its own rules for how the paper is signed and for who may act as your agent or witness. Read these legal requirements before you decide whom to ask. The next section puts them in plain words.

The FormsPal template pairs the appointment of an agent with an advance directive, which is a statement of your wishes about end-of-life care. It helps your agent make decisions that match what you want.

Principal, Agent and Alternate

• Principal. You, the person who signs the document.
• Agent. The person you name to make health care decisions for you.
• Alternate agent. A backup you may name on the FormsPal template, in case your first choice is unable to act.

California Medical Power of Attorney Requirements

California sets rules for signing and dating, for a notary or witnesses, and for who may serve as a witness or an agent. The rules come from sections 4659, 4673 and 4674 of the California Probate Code, which the sections below explain in plain words.

Signing and Dating the Document

The document must be signed by the principal, or in the principal's name by another adult in the principal's presence and at the principal's direction. It must also contain the date of its execution.^[2]

Notary or Witnesses

It needs one or the other, not both. The document must be either acknowledged before a notary public or signed by at least two witnesses.^[2]

Witness Restrictions

Who may serve as a witness is restricted by statute. None of these people may act as a witness:^[3]

• the principal's health care provider or an employee of the principal's health care provider
• the operator or an employee of a community care facility
• the operator or an employee of a residential care facility for the elderly

Agent Restrictions

State law restricts who may serve as agent. Except as the statute provides, these people may not make health care decisions as an agent:^[1]

• the supervising health care provider
• an employee of the health care institution where the principal is receiving care

Pick someone you trust and talk with them before you name them. That is common practice, not a legal requirement.

Form Details at a Glance

What Does the Template Cover?

The FormsPal template is titled California Medical Power of Attorney with Advance Directive. It has three numbered parts, a signature line and a final acknowledgment page. What each part says comes from the printed text of the template, not from California law. Review all of it before you sign.

• Part I, Power of Attorney for Health Care. You name your agent here, with the agent's phone and email, and you may name one alternate agent. A list of powers follows, lettered A to J, covering consent to medical care, access to medical records, pain relief and personal care. It also has a HIPAA release, so your agent can see your medical records.
• Part II, Advance Health Care Directive. This part states your wishes about end-of-life care and about relief from pain. The printed wording asks your providers to withhold or withdraw all treatments other than those needed to keep you comfortable under the conditions it lists.
• Part III, General Provisions. These are standard terms for the whole document. The date and signature lines come right after them.
• Acknowledgment. The last page is a block with the county, the date, the officer's name and title, and a signature and seal.

The template also covers an agent who is unable to act. In that case it says one document must be attached, such as a signed resignation, a physician's statement, a court order or a death certificate. Part II is a serious statement about end-of-life care, so check that it matches what you want. If it does not, ask a lawyer for advice or talk to your doctor before you sign.

Questions to Settle Before You Sign

A medical power of attorney works best when the people involved know what you want. These questions are common practice, not legal requirements. Decide your answers first, then ask your agent and your doctor to review them with you.

• Does the person you have in mind agree to serve as your agent?
• Would you like to name an alternate agent, in case your first choice is unable to act?
• Does your agent know your wishes about treatment, so the decisions they make match yours?
• Have you told your family who your agent is, so nobody is surprised later?
• Who will hold the original, and who will get copies?

This page covers health care decisions only. For money and property decisions, see our California durable power of attorney page or our California general power of attorney page.

Filling Out the California Medical Power of Attorney

The template has 21 fillable fields, and the five steps below follow it from page 1 to page 7. To start right away, use our fillable power of attorney form, or print the PDF and write your answers by hand. Each step names the part it covers.

The screenshots under each step show the FormsPal California medical power of attorney template filled with sample entries in blue, so you can see where each answer goes. The names, addresses, dates and amounts are examples only.

1. Enter the principal and the agent. On page 1, in paragraph 1 of Part I, enter your full name and home address as the principal. Next, enter the agent's full name and address. This is the person who will make health care decisions for you.

   

2. Add contact details and an alternate agent. Still on page 1, enter the agent's phone, email and alternative contact information. In the ALTERNATE AGENT paragraph, repeat the agent's name, then fill in the alternate's name, address and contact details. Leave the alternate blank if you want no alternate.

   

3. Date and sign on page 6. At the end of Part III on page 6, enter the date, sign on the signature line and print your name below it. California requires the document to contain the date of its execution.^[2] Ask the notary whether to sign ahead of time or at the appointment.

   

4. Complete the notary acknowledgment. On page 7, the notary acknowledgment block has fields for the county, the date, the officer's name and title, and the person who appeared, which is you. The notary completes this block and confirms your identity.

   

5. Notary signature and seal. The notary signs the Signature line at the bottom of page 7 and adds the official seal in the (Seal) space.

   

How to Sign and Use Your Medical Power of Attorney

Filling in the blanks is only part of the job. The steps below cover what happens around the template, from reading it to handing out copies. Follow the rules from the requirements section above.

1. Read the whole template. Go through Parts I to III and the last page, and check that Part II matches your wishes.
2. Check your agent. Confirm that your agent is not the supervising health care provider or an employee of the health care institution where you are receiving care. See who cannot be your agent.^[1]
3. Decide how to finish it. Either plan to have it acknowledged before a notary, or gather at least two witnesses who are not barred from acting.^[2][3]
4. Sign and date. The principal signs, or another adult signs in the principal's name, in the principal's presence and at the principal's direction. Add the date.^[2]
5. Keep and share copies. It is common practice to keep the original somewhere safe. California's statutory advance health care directive form, in Probate Code section 4701, tells you to give a copy of the signed form to your physician, to any other health care providers you may have, to any health care institution where you are receiving care, and to any health care agents you have named.^[4] Some people also add a California living will, which is a separate document.

The FormsPal template has no lines for witness names or signatures, only the acknowledgment on page 7. If you prefer two witnesses to a notary, ask a lawyer for legal advice on how to record their signatures before you sign.

Common Mistakes to Avoid

Most problems with a medical power of attorney come from skipped steps, not from the blanks on the template. These are the mistakes to watch for, based on the rules earlier on this page.

• Believing that both a notary and two witnesses are needed, when the document needs either one.^[2]
• Naming an agent who is the supervising health care provider or an employee of the health care institution where you are receiving care.^[1]
• Asking your health care provider, or an employee of a community care facility or a residential care facility for the elderly, to be a witness.^[3]
• Leaving the date blank, when the document must contain the date of its execution.^[2]
• Skipping Part II, which states your wishes about end-of-life care and deserves a careful reading before you sign.
• Leaving the only copy in a drawer, when it is common practice to give copies to your agent and your doctor.

Other California Forms
We provide a multitude of printable California templates to anyone looking for convenience when filling out various agreements, contracts, and other paperwork.

• California Last Will
• California Living Will
• California Small Estate Affidavit
• California Bill of Sale
• California Rental Lease Agreement
• California Eviction Notice

Download a Free California Medical Power of Attorney Form

You can download the California medical power of attorney as a PDF with 21 fillable fields, or build it online and print it. Either way, finish it the way California requires, with a notary or at least two witnesses.

Create a free high quality California Medical Power of Attorney online now!

Create and Print Online Now

General information, not legal or tax advice. Talk to a lawyer or your doctor about your own situation.

Sources

Unless noted otherwise, the sources below are from the California Probate Code, published by the California Legislative Information.

1. California Legislative Information. California Probate Code § 4659.
2. California Legislative Information. California Probate Code § 4673.
3. California Legislative Information. California Probate Code § 4674.
4. California Legislative Information. California Probate Code § 4701. Accessed October 15, 2026.

Mara Erlach

Writer & Attorney

Mara has been practicing estate planning and trust law in California since 2003, taking pride in helping clients of all backgrounds and asset profiles form a complete and customized estate plan. Her specialties are: estate planning, wills and trusts, trust and probate administration.