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California Durable Medical Power of Attorney Form |
The California Power Of Attorney For Health Care form is relevant to residents of the state of California. This document allows people to chose an `Agent` or agents who can represent them regarding their health care needs should they be unable through illness to represent them selves. In the event that the patient would want to suggest end-of-life procedures this document can also be used.
This document requires attestation by two (2) witnesses or a notary public in accordance with PROB § 4701.
How to Write
Enter name of Principal.
Part 1. Naming Agent And Alternative Agent
Enter Agents details
- Name
- Address
- ZIP code
- Home telephone number
- Work telephone number
Agents Authority Under HIPAA & CMIA
If the principal does not require any efforts to prolong life in certain situations.
- Initial
If there are any other relevant instructions.
- Enter details of other relevant instructions.
Part 2. Health Care Instructions
- Signature required to select the relevant health care instructions.
- Enter details of any other health care instructions required
Signature Of Principal
Enter principals details in prescence of witnesses.
- Signature
- Date
Statement Of Witnesses
Enter details of witnesses.
- Print name
- Signature
- Date
- Address
- ZIP code
One witness must complete the following declaration.
- Date
- Signature
Declaration Of Ombudsman Representative (Required if person appointing the agent currently resides in a nursing facility).
- Date
- Signature
Certificate Of Acknowledgement Of Notary Public. (Required if there is only one witness).
- County
- Date
- Name and title of notary
- Name of principal
- Signature of notary
