Advance Directive For Health Care (Page 2 of 7) in pdf

Advance Directive For Health Care Page 2

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS AND REHABILITATION

ADVANCE DIRECTIVE FOR HEALTH CARE

CDCR 7421 (REV. 09/09)

PART 1: Power of Attorney for Health Care

Optional: Naming of Primary Agent: I choose the following person as the person to make health care

decisions for me in the event that I am unable to make them myself. This person is called by agent.

I understand that this designation may be revoked by me anytime by verbal or written instruction.

__________________________________________________________________________________

(Name of person you choose as primary agent)

______________________________________________________________________________________________________________

(Address)

(City)

(State)

(Zip Code)

______________________________________________________________________________________________________________

(Home and/or Cell Phone Number)

(Work phone or a phone number of someone who can always reach agent)

Optional: Naming of First Alternate Agent: If the person named above is not willing, able, or

reasonably available to make health care decisions for me, I revoke their authority and choose the

following person instead to act as my agent.

I understand that this designation may be revoked by me anytime by verbal or written instruction.

__________________________________________________________________________________

(Name of person you choose as first alternate agent)

______________________________________________________________________________________________________________

(Address)

(City)

(State)

(Zip Code)

______________________________________________________________________________________________________________

(Home and/or Cell Phone Number)

(Work phone or a phone number of someone who can always reach agent)

Distribution: Original-UHR, Copy to Inmate

Page 2 of 7

Advance Directive For Health Care Page 2