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California Health Care Power of Attorney Form

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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 Page 2
California Health Care Power of Attorney Form
© 2004, Bet Tzedek Legal ServicesPage 2 of 4
2ND ALTERNATE AGENT (If Agent and 1ST Alternate Agent are unavailable or unwilling to serve.)
Name:
Address:
City State Zip
Home Phone: ( )
Work Phone: ( )
AGENT’S AUTHORITY
Except as limited by this document, my agent will have authority to make health care decisions for me to the extent that I
now have authority to make my own health care decisions. This authority includes, but is not limited to, the authority 1) to
accept or refuse treatment, nutrition and hydration, 2) to choose a particular physician or health care facility, and 3) to
receive, or consent to the release of, medical information and records.
Also, except as limited by this document, this authority includes the authority to authorize an autopsy, donate all or part of
my body, and/or determine the disposition of my remains. The agent’s actions must be consistent with my will or trust, and
with any funeral arrangements or other arrangements which I have made. (Cross this out if you do not wish your agent to
have this authority.)
AGENT’S AUTHORITY UNDER HIPAA & CMIA
My agent shall be my personal representative under HIPAA and CMIA and shall have the same rights to inspect, obtain and
disclose my protected health information as I have.
I make the following instructions to my agent:
I do not want efforts made to prolong my life and I do not want life-sustaining treatment to be provided or continued:
(1) if I am in an irreversible coma or persistent vegetative state; or (2) if I am terminally ill and the use of life-
sustaining procedures would serve only to artificially delay the moment of my death; or (3) under any other
circumstances where the burdens of treatment outweigh the expected benefits. In making decisions about life
sustaining treatment under (3) above, I want my agent to consider the relief of suffering and the quality of my life as
well as the extent of the possible prolongation of my life.
If this statement reflects your desires, initial here: _________
Other health care instruction to my agent:
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 willing, able or reasonably available to act as conservator, I nominate
the alternate agents whom I have named, in the order designated. (Cross out if not desired.)
AGENT’S OBLIGATIONS
1. My agent shall make decisions for me in accordance with this power of attorney, other instructions I make in this form
and my personal wishes, to the extent my agent knows them. If my wishes on a subject are not known, the agent shall
make decisions consistent with my best interest, taking into account my personal values to the extent they are known
to my agent.
2. My agent shall provide a copy of this advance health care directive to any health care provider or facility that takes on
responsibility for my care.
California Health Care Power of Attorney Form