Blank California Advanced Health Care Directive Form

The California Advanced Health Care Directive is a legal document that allows individuals to outline their healthcare preferences in the event they become unable to communicate their wishes. This form empowers people to designate a trusted person to make medical decisions on their behalf and to specify their treatment preferences. Understanding this directive is crucial for ensuring that one's healthcare choices are respected and upheld.

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Blank California Advanced Health Care Directive Form

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Misconceptions

When it comes to the California Advanced Health Care Directive form, many people have misunderstandings that can lead to confusion or misinformed decisions. Here are six common misconceptions:

It’s only for the elderly. Many believe that only older individuals need an Advanced Health Care Directive. In reality, anyone over the age of 18 can benefit from having this document in place, regardless of their health status.
It’s a legal document only for end-of-life situations. While it does address end-of-life care, it also covers decisions about medical treatment in various situations where a person may be unable to communicate their wishes, such as during a serious illness or injury.
It requires a lawyer to complete. Although consulting a lawyer can be helpful, it is not necessary. The form is designed to be user-friendly, allowing individuals to fill it out on their own, as long as they follow the instructions.
Once signed, it cannot be changed. This is a common myth. You can update or revoke your Advanced Health Care Directive at any time, as long as you are mentally competent to do so.
It only applies in California. While the form is specific to California, if you move to another state, your directive may still be honored, depending on that state’s laws. It’s important to check local regulations if you relocate.
It’s the same as a living will. Although they are similar, an Advanced Health Care Directive encompasses more than just a living will. It includes appointing a healthcare agent to make decisions on your behalf, which a living will does not.

Understanding these misconceptions can empower individuals to make informed decisions about their health care preferences and ensure their wishes are respected.

Detailed Steps for Filling Out California Advanced Health Care Directive

Filling out the California Advanced Health Care Directive form is an important step in ensuring that your healthcare wishes are known and respected. By completing this form, you can designate someone to make medical decisions on your behalf if you are unable to do so. This process is straightforward, and following these steps will help you navigate it with ease.

Begin by downloading the California Advanced Health Care Directive form from a reliable source, such as the California Department of Public Health website.
Read through the entire form carefully to understand what information is required.
In the first section, provide your full name, address, and date of birth.
Next, choose a healthcare agent. This is the person you trust to make medical decisions for you. Write their name, address, and phone number in the designated area.
Consider adding an alternate agent in case your primary choice is unavailable. Fill in their details if you choose to do so.
In the following section, you will find options regarding your healthcare preferences. Take your time to read each option and mark your choices clearly.
Once you have completed the preferences section, sign and date the form at the bottom. This signature confirms that you understand the document and agree to its terms.
Finally, have the form witnessed by two people who are not your healthcare agent or related to you. Alternatively, you can have it notarized if that is more convenient.

After completing the form, it is advisable to share copies with your healthcare agent, family members, and your doctor. This ensures that everyone involved is aware of your wishes and can act accordingly if the need arises.

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ADVANCE HEALTH CARE DIRECTIVE FORM		PAGE 1 of 7
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Probate Code - PROB

DIVISION 4.7. HEALTH CARE DECISIONS [4600 - 4806] ( Division 4.7 added by Stats. 1999, Ch. 658, Sec. 39. ) PART 2. UNIFORM HEALTH CARE DECISIONS ACT [4670 - 4743] ( Part 2 added by Stats. 1999, Ch. 658, Sec. 39. )

CHAPTER 2. Advance Health Care Directive Forms [4700 - 4701] ( Chapter 2 added by Stats. 1999, Ch. 658, Sec. 39. )

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

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 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)Donate your organs, tissues, and parts, 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, tissues, and parts 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.

ADVANCE HEALTH CARE DIRECTIVE FORM

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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)

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.

ADVANCE HEALTH CARE DIRECTIVE FORM

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(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 donate my organs, tissues, and parts, 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.)

(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 wiling, 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.)

	ADVANCE HEALTH CARE DIRECTIVE FORM	PAGE 4 of 7
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	PART 3
	DONATION OF ORGANS, TISSUES, AND PARTS AT DEATH
	(OPTIONAL)
(3.1)	Upon my death, I give my organs, tissues, and parts (mark box to indicate yes).

By checking the box above, and notwithstanding my choice in Part 2 of this form, I authorize my agent to consent to any temporary medical procedure necessary solely to evaluate and/or maintain my organs, tissues, and/or parts for purposes of donation.

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

(a)Transplant

(b)Therapy

(c)Research

(d)Education

If you want to restrict your donation of an organ, tissue, or part in some way, please state your restriction on the following lines:

If I leave this part blank, it is not a refusal to make a donation. My state-authorized donor registration should be followed, or, if none, my agent may make a donation upon my death. If no agent is named above, I acknowledge that California law permits an authorized individual to make such a decision on my behalf. (To state any limitation, preference, or instruction regarding donation, please use the lines above or in Section 1.5 of this form).

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)

ADVANCE HEALTH CARE DIRECTIVE FORM

PART 5

PAGE 5 of 7

(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:

(date)	(sign your name)
(address)	(print your name)

(city) (state)

(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)

(address)

(city)(state)

(print name)

(address)

(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)

ADVANCE HEALTH CARE DIRECTIVE FORM	PAGE 6 of 7

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.

(date)	(sign your name)
(address)	(print your name)
(city) (state)

(Amended by Stats. 2018, Ch. 287, Sec. 1. (AB 3211) Effective January 1, 2019.)

ADVANCE HEALTH CARE DIRECTIVE FORM

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ACKNOWLEDGMENT

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.

State of California,

County of

On	before me,

(insert name and title of officer)

personally appeared

who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person

(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature		(SEAL)

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Dos and Don'ts

When filling out the California Advanced Health Care Directive form, it’s essential to approach the task thoughtfully. This document allows you to express your healthcare wishes and appoint someone to make medical decisions on your behalf if you're unable to do so. Here’s a list of things to keep in mind:

Do read the entire form carefully before starting to fill it out.
Do discuss your wishes with family members and the person you intend to appoint as your healthcare agent.
Do be specific about your medical preferences and values to guide your healthcare agent.
Do sign and date the form in the presence of a witness or notary, as required.
Don't leave any sections blank; ensure all relevant information is provided.
Don't forget to give copies of the completed directive to your healthcare agent and family members.
Don't assume that verbal instructions will be enough; always document your wishes formally.

By following these guidelines, you can help ensure that your healthcare wishes are respected and understood. Taking the time to complete this form thoughtfully can provide peace of mind for both you and your loved ones.

Key takeaways

Filling out and using the California Advanced Health Care Directive form is an important step in planning for future healthcare needs. Here are key takeaways to consider:

Understand the Purpose: The directive allows individuals to express their healthcare preferences and appoint someone to make decisions on their behalf if they are unable to do so.
Eligibility: Any adult who is at least 18 years old can complete the form. It is essential to ensure that you are of sound mind when filling it out.
Choosing an Agent: Select a trusted person as your healthcare agent. This individual will be responsible for making medical decisions in accordance with your wishes.
Specific Instructions: Clearly outline your healthcare preferences, including your wishes regarding life-sustaining treatments, organ donation, and other medical interventions.
Witness Requirements: California law requires that the directive be signed in the presence of either two witnesses or a notary public. Ensure compliance to validate the document.
Review Regularly: It is advisable to review and update your directive periodically, especially after significant life changes such as marriage, divorce, or a change in health status.
Communicate Your Wishes: Share your completed directive with your healthcare agent, family members, and healthcare providers to ensure everyone is aware of your preferences.
Keep Copies Accessible: Store the original document in a safe place and provide copies to your healthcare agent and doctors to facilitate easy access when needed.

Being proactive in completing the California Advanced Health Care Directive can provide peace of mind, knowing that your healthcare wishes will be honored.

Similar forms

The California Advanced Health Care Directive is similar to a Living Will. A Living Will outlines an individual's wishes regarding medical treatment in situations where they are unable to communicate their preferences. Like the Advanced Health Care Directive, it focuses on end-of-life decisions, providing guidance to healthcare providers and loved ones about the type of care a person wishes to receive or avoid. Both documents aim to ensure that a person's healthcare choices are respected, even when they cannot speak for themselves.

Another document that shares similarities is the Durable Power of Attorney for Health Care. This legal document allows an individual to designate someone else to make healthcare decisions on their behalf if they become incapacitated. While the Advanced Health Care Directive can include specific treatment preferences, the Durable Power of Attorney focuses more on appointing a trusted person to act in one's best interests. Together, these documents create a comprehensive plan for healthcare decision-making.

The Do Not Resuscitate (DNR) Order also aligns closely with the California Advanced Health Care Directive. A DNR is a specific medical order that instructs healthcare providers not to perform CPR if a person's heart stops beating or they stop breathing. This document is often used in conjunction with an Advanced Health Care Directive, as both aim to clarify a person’s wishes regarding life-sustaining treatments. They work together to ensure that a person's end-of-life preferences are honored.

Another comparable document is the Physician Orders for Life-Sustaining Treatment (POLST). The POLST form is designed for individuals with serious health conditions and translates their treatment preferences into actionable medical orders. Like the Advanced Health Care Directive, it addresses specific medical interventions, but it is typically more detailed and immediate in nature. Both documents serve to communicate a person's healthcare wishes to medical professionals, ensuring that they receive the desired level of care.

Lastly, the Health Care Proxy is similar to the California Advanced Health Care Directive. This document allows an individual to appoint someone to make healthcare decisions on their behalf if they are unable to do so. While the Advanced Health Care Directive can include specific instructions about medical treatment, the Health Care Proxy primarily focuses on appointing a decision-maker. Both documents are essential for ensuring that a person's healthcare preferences are honored and that their chosen representative can advocate for them during critical times.

Documents used along the form

The California Advanced Health Care Directive form is a crucial document for individuals wishing to outline their medical preferences and appoint someone to make health care decisions on their behalf in the event they become unable to do so. In conjunction with this directive, several other forms and documents may be relevant for comprehensive health care planning. The following list outlines these documents, providing a brief description of each.

Durable Power of Attorney for Health Care: This document allows an individual to designate a specific person to make health care decisions on their behalf, similar to the health care agent appointed in the Advanced Health Care Directive.
Living Will: A living will specifies an individual's wishes regarding medical treatment in situations where they are terminally ill or permanently unconscious, focusing on end-of-life care preferences.
Do Not Resuscitate (DNR) Order: A DNR order instructs medical personnel not to perform CPR or other life-saving measures in the event of cardiac arrest, reflecting the individual's wishes regarding resuscitation.
POLST (Physician Orders for Life-Sustaining Treatment): This form translates a patient's treatment preferences into actionable medical orders, guiding health care providers in emergency situations.
Health Care Proxy: Similar to a durable power of attorney, a health care proxy designates an individual to make health care decisions, ensuring that someone is available to advocate for the patient’s wishes.
HIPAA Release Form: This form allows individuals to authorize the sharing of their medical information with designated persons, ensuring that family members or caregivers can access necessary health records.
Organ Donation Registration: This document allows individuals to express their wishes regarding organ donation after death, providing clarity to family members and medical personnel.
Estate Planning Documents: These may include wills and trusts that outline how an individual's assets will be managed and distributed after their death, complementing health care directives in overall planning.
Financial Power of Attorney: This document allows someone to manage financial matters on behalf of the individual, ensuring that financial decisions can be made if the individual is incapacitated.

Utilizing these documents alongside the California Advanced Health Care Directive can provide a more comprehensive approach to health care and personal planning. It is advisable to review these forms periodically and discuss them with family members or legal advisors to ensure that they reflect current wishes and circumstances.