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California Health Care Power of Attorney Form

The California health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.

California Health Care Power of Attorney Form
California Health Care Power of Attorney Form
© 2004; Bet Tzedek Legal Services, Los Angeles, California; (323) 939-0506; www.bettzedek.org
Permission to copy granted, if copies are not sold
CALIFORNIA POWER OF ATTORNEY FOR HEALTH CARE
AND HEALTH CARE INSTRUCTION FORM
NOTE:
COMPLETION OF THIS FORM IS ONLY THE FIRST STEP.
YOU SHOULD DISCUSS YOUR WISHES IN DETAIL WITH YOUR DESIGNATED AGENT(S).
WITH THIS FORM YOU MAY DO ANY OR ALL OF THE FOLLOWING:
1. NAME AN AGENT TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU CANNOT.
2. INSTRUCT DOCTORS AND OTHER HEALTH CARE PROFESSIONALS HOW YOU WOULD LIKE TO BE
TREATED IF YOU ARE HURT OR SERIOUSLY ILL AND UNABLE TO TELL THEM YOUR WISHES.
READ THE FORM CAREFULLY. CROSS OUT ANY PROVISION YOU DO NOT WANT.
THIS FORM REVOKES ANY PRIOR DIRECTIVES YOU HAVE MADE.
AFTER YOU COMPLETE THIS FORM SIGN AND DATE IT. TWO WITNESSES OR A NOTARY MUST ALSO SIGN AND DATE IT.
My name is:
.
In this document I appoint an agent. That agent will make health care decisions for me in the future, if and when I no longer
have the mental capacity to make my own health care decisions. My primary care physician will determine when I am
unable to make health care decisions for myself.
Part 1 - NAMING YOUR AGENT (If you do not have an agent, please proceed to Part 2 on page 3.)
The following persons cannot be selected as your agent or alternate agent:
Your primary physician.
An employee of the health care institution or residential care facility where you receive care
(unless you are related to that person).
AGENT
Name:
Address:
City State Zip
Home Phone: ( )
Work Phone: ( )
1ST ALTERNATE AGENT (If Agent is unavailable or unwilling to serve.)
Name:
Address:
City State Zip
Home Phone: ( )
Work Phone: ( )
California Health Care Power of Attorney Form
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