California Advance Health Care Directive Form

California Advance Health Care Directive Form - 2008

CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE

Including Power of Attorney for Health Care

Imprint / MRN

PART 1:

APPOINTING AN AGENT TO MAKE HEALTH CARE DECISIONS

NOTE: You should discuss your wishes in detail with your designated agent(s)

My name is:__________________________________ Date of Birth:_______________

1 A

My address is:____________________________________________________________

In this document I appoint an agent. I want this person to help make my medical

decisions.

Your agent or alternate agent cannot be:

 Your primary physician

 Someone who works where you receive care (unless you are related to that person

or you are co-workers).

PRIMARY AGENT:

Agent’s Name: ___________________________________________________

1 B

Address:_________________________________________________________

Phone: ____________________________________________________

(Indicate home, work, pager, and cellular phone)

ALTERNATE AGENT (If Agent is not willing, able, or reasonably available to

serve.)

Name of first alternate agent

: ____________________________________________________

__________________________________________________

Address:

Phone: ____________________________________________________

(Indicate home, work, pager, and cellular phone)

2nd ALTERNATE AGENT (If Agent and 1

Alternate are unavailable or unwilling to

serve.)

Name of second alternate agent: _______________________________________

___________________________________________________

Address:

Phone: ____________________________________________________________

(Indicate home, work, pager, and cellular phone)

WHEN WILL MY AGENT MAKE DECISIONS:

(Put an X next to the sentence you agree with.)

 My health care agent can make health care decisions for me now. ______(initial here)

1 C

 My health care agent will make health care decisions for me ONLY when I do not have

the mental capacity to make my own health care decisions. ______(initial here)

Page 1 of 4

5/12/08

California Advance Health Care Directive Form - 2008

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