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California Advance Health Care Directive
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.
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.
* * * * * * * * * * * * * * * * *
(1.1) DESIGNATION OF AGENT: I designate the following
individual as my agent to make health care decisions for me:
If you fill out this part of the form, you may strike any
wording you do not want.
(3.1) Upon my death (mark applicable box):
(4.1) I designate the following physician as my primary
* * * * * * * * * * * * * * * * *
(5.1) EFFECT OF COPY: A copy of this form has the same
effect as the original.
(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 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.
(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.
(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.
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