Advance Health Care Directive — Health Care Instructions
ADVANCE HEALTH CARE DIRECTIVE — CALIFORNIA California Probate Code Section 4701 You have the right to give instructions about your own physical and mental health care. You also have the right to name someone else to make those health care decisions for you. This Locke Direct product completes treatment instructions only. The statutory form may be completed or modified in all or any part. PART 1 — POWER OF ATTORNEY FOR HEALTH CARE VOID / NOT COMPLETED IN THIS STANDALONE LIVING WILL. No agent, alternate agent, conservator nominee, or post-death agent authority is created by this product. PART 2 — INSTRUCTIONS FOR HEALTH CARE If you fill out this part of the form, you may strike any wording you do not want. (2.1) END-OF-LIFE DECISIONS I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice marked below: the information supplied in the interview (2.2) RELIEF FROM PAIN the information supplied in the interview the information supplied in the interview WISHES FOR PHYSICAL AND MENTAL HEALTH CARE I direct that: the information supplied in the interview the information supplied in the interview PART 3 — DONATION OF ORGANS, TISSUES, AND PARTS AT DEATH NOT COMPLETED IN THIS STANDALONE LIVING WILL. This is not a refusal of donation. The statutory form states that leaving this part blank is not a refusal to make a donation. Any valid state-authorized donor registration or later lawful decision remains separate from this product. PART 4 — PRIMARY PHYSICIAN NOT COMPLETED IN THIS STANDALONE LIVING WILL. This product does not designate a primary physician. PART 5 — SIGNATURE AND EXECUTION 5.1 EFFECT OF COPY A copy of this form has the same effect as the original. 5.2 SIGNATURE Date: the information supplied in the interview Sign your name: Print your name: the information supplied in the interview Address: the information supplied in the interview 5.3 STATEMENT OF WITNESSES If the witness route is used, each witness declares under penalty of perjury under the laws of California (1) that the individual who signed or acknowledged this advance health care directive is personally known to the witness, or that the individual's identity was proven to the witness by convincing evidence, (2) that the individual signed or acknowledged this advance directive in the witness's presence, (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that the witness is not a person appointed as agent by this advance directive, and (5) that the witness is not the individual's health care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly. First witness: Print name / address: Signature / date: Second witness: Print name / address: Signature / date: 5.4 ADDITIONAL STATEMENT OF WITNESSES At least one of the above witnesses must also sign the following declaration: I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the individual's estate upon their death under a will now existing or by operation of law. Additional witness signature: OR — NOTARY ACKNOWLEDGMENT If the notary route is used instead of two witnesses, use a current California acknowledgment certificate. PART 6 — SPECIAL WITNESS REQUIREMENT The following statement is required only if you are a patient in a skilled nursing facility — a health care facility that provides skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. Under Probate Code § 4675, if the individual is a patient in a skilled nursing facility when a written advance health care directive is executed, the advance directive is not effective unless a patient advocate or ombudsman signs as a witness, either as one of two witnesses or in addition to notarization. the information supplied in the interview STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN I declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and that I am serving as a witness as required by Section 4675 of the Probate Code. Patient advocate / ombudsman signature: Print name / address: Date: the information supplied in the interview This Advance Health Care Directive is not California POLST and is not a Prehospital DNR medical order.