Fillable Registration Of Written Advance Health Care Directive (Page 2 of 2) in pdf

INSTRUCTIONS

Registering a written advance health care directive (directive) or its location is voluntary. Registration or failure

to register does not affect the validity of the directive.

A directive or information regarding the location of a directive may be filed with the Secretary of State pursuant to

Probate Code sections 4800-4805 by using this form. If any information on the registration form changes, or if the actual

directive is revoked (changed), the registrant complete and submit this form to the Secretary of State.

A registrant must re-register upon execution of a subsequent directive.

1. If this is a new registration of your directive, check the New Registration box on the form and complete the entire form.

Attach to the form a check payable to the Secretary of State in the amount of $10.00 and mail the check and completed

form to the address below.

If this is an amendment or change to a registration form that you have previously filed with the Secretary of State (for

example, a change of address or a change in the location of your directive), check the Amendment box on the form,

complete Items 3 and 7, and provide the information that changed in the applicable section. There is no filing fee. Mail the

completed form to the address below.

If this is notification that your directive previously registered with the Secretary of State has been revoked or has changed,

and you are not registering a new directive with the Secretary of State, OR if you want to revoke your prior registration of

your directive with the Secretary of State, check the Revocation Only box on the form and complete Items 3 and 7. There is

no filing fee. Mail the completed form to the address below.

If this is notification that your directive previously registered with the Secretary of State has been revoked or has changed,

and you want to register a new Directive with the Secretary of State, check the Revocation (change) of Prior Directive and

New Registration box on the form and complete the entire form. Attach to the form a check payable to the Secretary of

State in the amount of $10.00 for the new registration and mail the check and completed form to the address below.

2. Check the appropriate statement indicating if your directive is attached to this form or if you are providing the location of the

directive.

3. Print your name, address, date of birth and place of birth. Also include at least one of the following: social security number,

driver’s license number and state or country of issuance, or another form of identification issued by a government agency.

The identification numbers will not be disclosed to the public; however, they will be used by this office to ensure the correct

information for the correct person is provided to your health care provider when requested.

4. Print the full name and telephone number of your agent, if any, who is authorized to make health care decisions for you as

indicated in your directive.

5. Print the full name and telephone number of your alternate agent, if any, who is authorized to make health care decisions

for you as indicated in your directive

6. Provide the address or location of the directive (e.g. safe in the closet in the spare room at 123 Any Street, Any City, CA

99999) if this is the purpose of the registration.

7. Sign, date and type or print your name below.

If you are unable to fill out or sign the form, another adult can complete it in your presence and at your direction. (2 Cal. Code

of Regs. Section 22610.2(a))

Mail the completed form and any applicable filing fees to:

Secretary of State, Special Filings Unit, P.O. Box 942877, Sacramento, CA 94277-0001 (916) 653-3984

Note: Should you wish to register your organ and tissue donation choices, please do so with Donate Life, California’s official

Organ and Tissue Donor Registry, at

Pursuant to Probate Code section 4800 and 2 Cal. Code of Regs. section 22610.2, the information on this form is requested by the Secretary of State’s Office,

Special Filings Unit, P.O. Box 942877, Sacramento, CA 94277-0001, Telephone number (916) 653-3984. Providing the information is necessary in order to

identify you should there be a request to receive information as specifically authorized by law. Information received on lines 3(a), 3(b), and 3(c) of the form will

not be disclosed except as specifically authorized by law, although at least one of the items must be provided by you for identification purposes.

SFL-461 (Rev 01/13)