MAKE YOUR FREE Advance Directive

ADVANCE HEALTH CARE DIRECTIVE

(California Probate Code 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 you 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 to 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 give the authority to your agent to authorize autopsy and disposition of your remains.

Part 5 of this form lets you give the authority to your agent to signed forms under HIPAA that refers to the release of your medical records.

Part 6 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 provider 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

. DESIGNATION OF AGENT. I, , residing at , , , do hereby designate the following individual as my agent to make health care decisions for me:

Agent:

. 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

. 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

. 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.

PART 2

INSTRUCTIONS FOR HEALTH CARE

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 this part of the form.

. 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 initialed below:

. ARTIFICIAL NUTRITION AND HYDRATION. Artificial nutrition and hydration must be provided, withheld or withdrawn in accordance with the choice I have made in paragraph

. RELIEF FROM PAIN.

PART 3

DONATION OF ORGANS AT DEATH

PART 4

AUTOPSY AND DISPOSITION ON REMAINS

. Upon my death, I give the authority to my agent to authorize an autopsy make determinations for disposition of my remains.

PART 5

AUTHORIZATION TO SIGN FORMS UNDER HIPAA

. With this document I authorize my agent to sign all forms required under HIPAA that refer but are not limited to the release of my medical records.

PART 6

PRIMARY PHYSICIAN

. I designate the following physician as my primary physician:

Physician:

If a primary physician is not selected under part 6, then I request that the rules of California Medical Association be applied for the identification of my primary physician.

PART 7

. EFFECT OF COPY. A copy of this form has the same effect as the original.

. SIGNATURE.

NOTICE: SPECIAL RULES APPLY IF YOU ARE A RESIDENT OF A SKILLED NURSING FACILITY. IF YOU RESIDE IN SUCH A FACILITY, THIS DOCUMENT MUST BE SIGNED BY A PATIENT ADVOCATE OR OMBUDSMAN. IF YOUR DOCUMENT IS BEING WITNESSED BY TWO WITNESSES, ONE OF THOSE WITNESSES MUST BE THE ADVOCATE OR OMBUDSMAN WHO SIGNS ALL WITNESS STATEMENTS. IF YOUR DOCUMENT IS BEING NOTARIZED, THE ADVOCATE OR OMBUDSMAN MUST SIGN THE SPECIAL WITNESS REQUIREMENT SECTION.

. STATEMENT OF WITNESSES: [If you are a resident in a skilled nursing facility, a patient advocate or ombudsman must sign this statement as one of your two 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,

(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, and

(6) that I am an adult.

. ADDITIONAL STATEMENT OF WITNESSES. At least one of the above witnesses must also sign the following declaration. [If you are a resident in a skilled nursing facility, the patient advocate or ombudsman must sign this statement.]

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.

PART 8

. SPECIAL WITNESS REQUIREMENT.

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.

I further declare:

(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,

(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,

(6) that I am an adult, and

(7) 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.

When you complete this form, you are advised that you may not regard this form as completed with the assistance of an attorney.