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.  Two witnesses, one of which may be a notary and one of which may not be a relative or facilitator of health care to the principal. The document adheres the US statute §§ 4600 – 4806.

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