Free California Advanced Health Care Directive PDF Form

The California Advanced Health Care Directive is a legal document that allows individuals to express their healthcare preferences in advance, ensuring their wishes are honored if they become unable to communicate them. This directive can appoint a trusted person to make medical decisions on your behalf and outline specific treatment preferences. Understanding this form is essential for anyone who wants to maintain control over their healthcare choices in challenging times.

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When it comes to making decisions about healthcare, especially in moments of crisis, having a plan in place can provide peace of mind for both individuals and their loved ones. The California Advanced Health Care Directive is a crucial tool that allows individuals to outline their medical preferences and appoint someone to make decisions on their behalf if they become unable to communicate their wishes. This form encompasses two primary components: the designation of an agent, who will act as a healthcare proxy, and the expression of specific healthcare preferences, which can include directives about life-sustaining treatments, pain management, and organ donation. By taking the time to complete this directive, individuals can ensure that their values and desires are respected, even when they are unable to voice them. Furthermore, the form is designed to be flexible, allowing for updates and revisions as personal circumstances and preferences change over time. Understanding the nuances of this directive is essential for anyone looking to navigate the complexities of healthcare decisions, making it a vital aspect of personal planning in California.

California Advanced Health Care Directive Sample

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)

Documents used along the form

The California Advanced Health Care Directive is an essential document that allows individuals to express their wishes regarding medical treatment and appoint someone to make healthcare decisions on their behalf if they become unable to do so. Along with this directive, several other forms and documents can complement its purpose, providing clarity and guidance in medical situations. Below is a list of commonly used forms that often accompany the California Advanced Health Care Directive.

Durable Power of Attorney for Health Care: This document designates a specific person to make healthcare decisions for you if you are incapacitated. It can be tailored to include specific instructions regarding treatment preferences.
Do Not Resuscitate (DNR) Order: A DNR order instructs medical personnel not to perform CPR if your heart stops or you stop breathing. This document is crucial for those who wish to avoid aggressive resuscitation efforts.
POLST (Physician Orders for Life-Sustaining Treatment): This form translates your healthcare wishes into actionable medical orders. It is particularly useful for individuals with serious illnesses, ensuring that their preferences are honored by medical staff.
Living Will: A living will outlines your preferences for medical treatment in situations where you cannot communicate your wishes. It typically addresses end-of-life care and specific medical interventions you may or may not want.
Health Insurance Portability and Accountability Act (HIPAA) Authorization: This form allows you to designate individuals who can access your medical records and discuss your health information with healthcare providers, ensuring your privacy is respected.
Organ Donation Consent: This document indicates your wishes regarding organ donation after death. It can provide peace of mind knowing your preferences are documented and respected.
Financial Power of Attorney: While not directly related to healthcare, this document allows someone to manage your financial affairs if you become incapacitated. It ensures that your financial needs are met during difficult times.
Quitclaim Deed: A Quitclaim Deed is essential for transferring property ownership seamlessly. For more detailed information, visit Illinois Templates PDF.
Advance Care Planning Conversations: While not a formal document, having discussions with family and healthcare providers about your wishes can help clarify your desires and ensure everyone is on the same page.

Each of these documents plays a vital role in ensuring that your healthcare preferences are honored and that your loved ones are prepared to make decisions on your behalf if necessary. Taking the time to complete these forms can provide peace of mind for you and your family, knowing that your wishes will be respected in challenging situations.

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Key takeaways

Filling out the California Advanced Health Care Directive form is a crucial step in ensuring your healthcare wishes are honored. Here are key takeaways to consider:

Understand the Purpose: This form allows you to specify your healthcare preferences and appoint someone to make decisions on your behalf if you become unable to do so.
Choose an Agent Wisely: Select a trusted individual who understands your values and will advocate for your wishes. This person should be someone you can communicate openly with about your healthcare preferences.
Be Clear and Specific: When detailing your healthcare preferences, clarity is vital. Specify your wishes regarding life-sustaining treatments, organ donation, and other medical interventions.
Discuss with Your Agent: Before completing the form, have a conversation with your chosen agent. Ensure they are willing to take on this responsibility and understand your desires.
Sign and Date the Form: Proper execution of the directive is essential. Sign and date the document in the presence of a witness or a notary public, as required by California law.
Keep Copies Accessible: After completing the form, keep copies in easily accessible locations. Share them with your agent, family members, and healthcare providers to ensure everyone is informed of your wishes.
Review and Update Regularly: Your healthcare preferences may change over time. Review your directive periodically and update it as necessary to reflect your current wishes.

Taking these steps can help ensure that your healthcare decisions are respected and followed, providing peace of mind for you and your loved ones.

Form Overview

Fact Name	Description
Purpose	The California Advanced Health Care Directive allows individuals to specify their healthcare preferences and appoint an agent to make medical decisions on their behalf if they become unable to do so.
Governing Law	This directive is governed by the California Probate Code, specifically sections 4600-4800.
Agent Appointment	Individuals can appoint a healthcare agent who will have the authority to make medical decisions according to the individual's wishes.
Living Will	The directive can include a living will, outlining specific wishes regarding life-sustaining treatment.
Signature Requirement	The form must be signed by the individual and either witnessed by two adults or notarized to be legally valid.
Revocation	Individuals can revoke or change their directive at any time, as long as they are mentally competent.
Healthcare Provider Obligations	Healthcare providers must follow the instructions outlined in the directive, provided they are aware of it and it is valid.
Durability	The directive remains in effect even if the individual becomes incapacitated, ensuring that their wishes are honored.
Age Requirement	Individuals must be at least 18 years old to complete and sign the directive.
Availability	The California Advanced Health Care Directive form is available online and can be downloaded for free from various legal and healthcare websites.

Frequently Asked Questions

What is a California Advanced Health Care Directive?

The California Advanced Health Care Directive is a legal document that allows individuals to outline their preferences for medical treatment in the event they become unable to communicate their wishes. It serves two primary purposes: designating an agent to make healthcare decisions on one’s behalf and providing specific instructions regarding medical care. This directive ensures that a person’s healthcare choices are respected and followed, even when they cannot express them directly.

Who can create an Advanced Health Care Directive in California?

Any adult who is at least 18 years old and of sound mind can create an Advanced Health Care Directive in California. This includes individuals who are capable of understanding the nature and consequences of their decisions regarding medical care. It is important to note that while anyone can create this directive, it must be signed in the presence of a witness or notarized to be legally valid.

What should I include in my Advanced Health Care Directive?

When completing an Advanced Health Care Directive, individuals should consider including the following elements:

Designation of an Agent: Choose a trusted person to make healthcare decisions on your behalf.
Specific Medical Instructions: Clearly outline your preferences regarding life-sustaining treatments, resuscitation efforts, and other medical interventions.
Organ Donation Wishes: Indicate whether you wish to donate your organs or tissues after death.
End-of-Life Preferences: Specify any preferences regarding hospice care, pain management, and other end-of-life considerations.

Including these details can provide clarity and guidance to your healthcare agent and medical providers, ensuring your wishes are honored.

How do I revoke or change my Advanced Health Care Directive?

Revoking or changing an Advanced Health Care Directive is a straightforward process. To revoke the directive, an individual can simply destroy the document or state their intention to revoke it in writing. If changes are desired, a new directive can be created to replace the old one. It is essential to inform the designated healthcare agent and any healthcare providers of the changes to ensure that they are aware of the updated wishes.

Is an Advanced Health Care Directive the same as a Do Not Resuscitate (DNR) order?

No, an Advanced Health Care Directive and a Do Not Resuscitate (DNR) order are not the same, although they can be related. An Advanced Health Care Directive encompasses a broader range of healthcare decisions and preferences, while a DNR specifically instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) if a person's heart stops beating or they stop breathing. It is advisable to have both documents if one wishes to ensure comprehensive healthcare planning.

Click for California Advanced Health Care Directive PDF

Misconceptions

The California Advanced Health Care Directive form is an essential document for anyone looking to outline their healthcare preferences in advance. However, several misconceptions surround this form, which can lead to confusion and misinformed decisions. Here are five common misconceptions:

1. The form is only for the elderly or terminally ill. Many people believe that only those who are elderly or facing serious health issues need an Advanced Health Care Directive. In reality, anyone over the age of 18 can benefit from this document. It ensures that your healthcare wishes are known and respected, regardless of your current health status.
2. Completing the form means I cannot change my mind later. Some individuals think that once they fill out the directive, their choices are set in stone. This is not true. You can update or revoke your directive at any time, as long as you are mentally competent. It’s important to review your preferences periodically, especially after significant life changes.
3. The form only covers end-of-life decisions. While many associate the directive with end-of-life care, it actually encompasses a wide range of healthcare decisions. This includes preferences for treatments, medications, and interventions in various medical situations, not just those at the end of life.
4. I need a lawyer to fill out the form. Some people think that legal assistance is necessary to complete the Advanced Health Care Directive. However, the form is designed to be user-friendly. You can fill it out on your own, as long as you follow the instructions carefully. If you have specific legal questions, consulting a lawyer can be helpful, but it’s not a requirement.
5. My healthcare provider will automatically know my wishes. Many assume that simply having an Advanced Health Care Directive means their healthcare providers will be aware of their wishes. This is a misconception. It is crucial to discuss your directive with your healthcare team and ensure that they have a copy on file. Communication is key to making sure your preferences are honored.

Understanding these misconceptions can empower individuals to take control of their healthcare decisions and ensure that their wishes are respected when it matters most.