Advance Health Care Directive Form - State Of California printable pdf download

ADVANCE HEALTH CARE DIRECTIVE

OF ______________________________________________________________

(Name)

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 the designation of a primary practitioner or a primary physician in case you

seek medical assistance such as the setting of a broken bone. 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 reasonable 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) Direct disposition of your remains and make anatomical gifts.

Part 2 of this form lets you give specific instructions about any aspect of your health care, whether or not you

appoint an agent. This is where you can 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 provided for you to

write out any specific wishes you may have about your health care. If you wish to rely exclusively on Christian

Science treatment for your care, you need not fill in the blank lined portion of Part 2 of this form.

Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death.

Part 4 requests that no autopsy be performed on your remains. However, the final decision lies with the

County Coroner.

Part 5 of this form lets you designate a practitioner or a physician to have primary responsibility for your health

care.

Part 6 of this form relieves your agent from liability for choosing Christian Science treatment for you.

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.

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Advance Health Care Directive Form - State Of California

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