Advance Health Care Directive
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2MH 635
ADVANCE HEALTH CARE DIRECTIVE
Revised 02/15/11
ACKNOWLEDGEMENT FORM
Page 1 of 2
Background
In accordance with California Probate Code 4600 et seq. and Federal requirements under Title 42,
clients 18 years of age and older shall receive information about Advance Health Care Directives
and be informed of their right to make decisions about their medical treatment.
To Be Completed by Staff
The client was given a copy of the Advance Health Care
Yes
No
Directive Fact Sheet at the first face-to-face contact or clinic
visit.
If "No" please explain why the client was not given the Fact Sheet:
Does the client have an Advance Health Care Directive
Yes
No
currently in place?
If the client would like to execute an Advance Health Care Directive, please refer them to the
resources identified on the Fact Sheet. If a client already has an Advance Health Care Directive,
insert a copy into the client's Clinical Record in Section 2 (Consents and Notices).
To Be Completed by the Client/Responsible Adult*
I have been asked about having an Advance Health Care Directive, and I have been given or offered
an Advance Health Care Directive Fact Sheet.
____________________________________________
__________________
Signature of Client
Date
____________________________________________
__________________
__________________
Signature of Responsible Adult*
Relationship to Client
Date
____________________________________________
__________________
Signature of Witness/Interpreter **
Date
This Form was interpreted in ____________________ for the client and/or responsible adult.
If a translated version of this Form was signed by the client and/or responsible adult, the translated version must be attached to the English version.
Signator
was given
declined a copy of this Form on ______________ by ________.
Date
Initials
*
Responsible Adult = Guardian, Conservator, or Parent of minor when required.
** Witness/Interpreter = Person who either witnessed the signing of the form (may be staff or other person) or the person who
interpreted this form into another language for the client (must include the language it was interpreted into).
This confidential information is provided to you in accord with State and Federal laws and
Name:
IS#:
regulations including but not limited to applicable Welfare and Institutions code, Civil Code and
HIPAA Privacy Standards. Duplication of this information for further disclosure is prohibited
Agency:
Provider #:
without prior written authorization of the client/authorized representative to whom it pertains
unless otherwise permitted by law. Destruction of this information is required after the stated
Los Angeles County – Department of Mental Health
purpose of the original request is fulfilled.
ADVANCE HEALTH CARE DIRECTIVE
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