Advance Health Care Directive

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Includes Power of Attorney for Health Care and Living Will.

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This Advance Health Care Directive is made up two documents, a Power of Attorney for Health Care and a Living Will. It is a wise choice for anyone to have these documents in place. If the unexpected happens, these documents will not only give you, but your loved ones peace of mind knowing that your wishes are being carried out. If you are already sick or disabled, these documents are all the more important, as they will not only give your loved ones guidance, but your physicians as well.

A Power of Attorney for Health Care is extremely important should you be unable to make decisions for yourself due to illness or incapacity. This form allows a person (also known at the "principal") to designate a trusted individual (family member or friend) as their "attorney in fact" (or "health care agent") to make critical health care decisions on their behalf. The Principal can give specific instructions regarding their health care, opt to have their organs donated if they wish, and may designate a specific physician to have primary responsibility over their health care.

A Living Will is a document that will specify your exact wishes with regard to your health care should you become incapacitated. This document will outline when and if you want life prolonging treatments. It is important to note that these documents do not go into effect until you are actually incapacitated. Until that time they may be amended or cancel the document verbally should you change your mind on any provision.

These Forms include the Following Key Provisions:
  • Living Will: This document will identify the care you would like to have if you become incapacitated or injured and are unable to speak for yourself. It includes specifics including the use of life saving measures, and whether to use them or not;
  • Life Sustaining Options: You will have the opportunity to specifically choose if you want food and hydration, and artificial life support.
  • Representative: You will appoint a specific person, (usually a close family member or friend), to act as your representative. This person will speak for you and if need be make decisions on your behalf;
  • Your Unique Wishes: You will be able to identify what specific types of life saving measures you would like taken, and you will be able to add any extra instructions not otherwise mentioned.

This attorney prepared packet contains:
  1. Information and Instructions for Advance Directive for Health Care (Power of Attorney for Health Care and Living Will);
  2. Advance Directive for Health Care (Power of Attorney for Health Care and Living Will) Form.
Law Compliance: This form complies with the laws of your state.
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.






ADVANCE HEALTH CARE DIRECTIVE
(California Probate Code Section 4701)

You have the right to give instructions about your own health care.  You also have the right to name someone else to make health-care decisions for you.  This form lets you do either or both of these things.  It also lets you express your wishes regarding donation of organs and the designation of your primary physician.  If you use this form, you may complete or modify all or any part of it.  You are free to use a different form.

Part 1 of this form is a Power of Attorney for Health Care.  Part 1 lets you name another individual as agent to make health-care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable.  You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you.  (Your agent may not be an operator or employee of a community care facility or a residential care facility where you are receiving care, or your supervising health care provider or employee of the health care institution where you are receiving care, unless your agent is related to you or is a coworker.  Additionally, you should consult an attorney before designating your conservator as your agent.)

Unless the form you sign limits the authority of your agent, your agent may make all health-care decisions for you.  This form has a place for you to limit the authority of your agent.  You need not limit the authority of your agent if you wish to rely on your agent for all health-care decisions that may have to be made.  If you choose not to limit the authority of your agent, your agent will have the right to:

(a) Consent or refuse to consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition.
(b) Select or discharge health-care providers and institutions.
(c) Approve or disapprove diagnostic tests, surgical procedures, and programs of medication.
(d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation.
(e) Make anatomical gifts, authorize an autopsy, and direct disposition of remains.

Part 2 of this form lets you give specific instructions about any aspect of your health care, whether or not you appoint an agent.  Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to keep you alive, as well as the provision of pain relief.  Space is also provided for you to add to the choices you have made or for you to write out any additional wishes.  If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out Part 2 of this form.

Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death.

Part 4 of this form lets you designate a physician to have primary responsibility for your health care.  After completing this form, sign and date the form at the end. The form must be signed by two qualified witnesses or acknowledged before a notary public.  Give a copy of the signed and completed form to your physician, to any other health-care provider you may have, to any health-care institution at which you are receiving care and to any health-care agents you have named.  You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility.

You have the right to revoke this advance health-care directive or replace this form at any time.

PART 1 - POWER OF ATTORNEY FOR HEALTH CARE

(1.1) DESIGNATION OF AGENT:  I designate the following individual as my agent to make health care decisions for me:

Name of individual you choose as agent: ____________________________________
Address: _____________________________________________________________
City, State, Zip Code: ___________________________________________________
Phone Home _____________________ Work: ______________________________


OPTIONAL:  If I revoke my agent's authority or if my agent is not willing,  able, or reasonably available to make a health care decision for me, I  designate as my first alternate agent:


Name of individual you choose as alternate agent: ____________________________
Address: _____________________________________________________________
City, State, Zip Code: ___________________________________________________
Phone Home _____________________ Work: ______________________________


OPTIONAL:  If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate agent:


Name of individual you choose as second alternate agent: ______________________
Address: _____________________________________________________________
City, State, Zip Code: ___________________________________________________
Phone Home _____________________ Work: _______________________________


   (1.2) AGENT'S AUTHORITY:  My agent is authorized to make all health care
  decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________
(Add additional sheets if needed.)

(1.3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE:  My agent's authority ecomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box.
If I mark this box o my agent's authority to make health care decisions for me takes effect immediately.

 (1.4) AGENT'S OBLIGATION:  My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

(1.5) AGENT'S POSTDEATH AUTHORITY:  My agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains, except as I state here or in Part 3 of this form:
______________________________________________________________________

______________________________________________________________________

______________________________________________________________________
(Add additional sheets if needed.)

   (1.6) NOMINATION OF CONSERVATOR:  If a conservator of my person needs to
  be appointed for me by a court, I nominate the agent designated in this form.  If that agent is not willing, able, or reasonably available to act as conservator, I nominate the alternate agents whom I have named, in the order designated.


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 I have marked below:
    
o (a) Choice Not To Prolong Life
I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits,

OR
    
o (b) Choice To Prolong Life
   I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

(2.2) RELIEF FROM PAIN:  Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death:
______________________________________________________________________

______________________________________________________________________
(Add additional sheets if needed.)

   (2.3) OTHER WISHES:  (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.)  I direct that:
______________________________________________________________________

______________________________________________________________________
(Add additional sheets if needed.)



PART 3 - DONATION OF ORGANS AT DEATH - (OPTIONAL)

  (3.1) Upon my death (mark applicable box):
  
o (a) I give any needed organs, tissues, or parts, OR
  
o (b) I give the following organs, tissues, or parts only: _________________________

_______________________________________________________________________


      (c) My gift is for the following purposes (strike any of the
      following you do not want):
          (1) Transplant
          (2) Therapy
          (3) Research
          (4) Education


PART 4 - PRIMARY PHYSICIAN - (OPTIONAL)

   (4.1) I designate the following physician as my primary physician:

Name of physician: _____________________________________________________
Address: _____________________________________________________________
City, State, Zip Code: ___________________________________________________
Phone: _______________________________________________________________

  OPTIONAL:  If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I designate the following physician as my primary physician:

Name of physician: _____________________________________________________
Address: _____________________________________________________________
City, State, Zip Code: ___________________________________________________
Phone: _______________________________________________________________


PART 5

  (5.1) EFFECT OF COPY:  A copy of this form has the same effect as the original.

  (5.2) SIGNATURE:  Sign and date the form here:

Date: ______________________________________________
Sign your name ______________________________________
Print your name ______________________________________
Address ____________________________________________
City _______________________________________________
State _______________________________________________
 

    (5.3) STATEMENT OF WITNESSES:  I declare 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 me, or that the individual's identity was proven to me by convincing evidence (2) that the individual signed or acknowledged this advance directive in my presence,  (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a person appointed as
agent by this advance directive, and (5) that I am 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 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
Name: _____________________________________________
Address: ___________________________________________
Signature of Witness: _________________________________
Date: ______________________________________________


SECOND WITNESS
Name: _____________________________________________
Address: ___________________________________________
Signature of Witness: _________________________________
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 his or her death under a will now existing or by operation of
law.

Signature of Witness: ___________________________________

Signature of Witness: ___________________________________


PART 6 - SPECIAL WITNESS REQUIREMENT

  (6.1) The following statement is required only if you are a patient in a skilled nursing facility--a health care facility that provides the following basic services:  skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis.  The patient advocate or ombudsman must sign the following statement:

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.


Date: _____________________________________________
Name: ____________________________________________
Sign your name _____________________________________
Print your name: ___________________________________
Address: __________________________________________
City:  _____________________________________________
State: _____________________________________________



Number of Pages7
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#16841

Customer Reviews

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Reviews: 5


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This form is very good and easy to purchase on line.


Nokomis,

FL

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I was very pleased with the 3 products I purchesed. The living Trust was a little confusing until I realized that filling out the questions did not enter the information in the final form and that these had to be reentered.


Sarasota,

FL

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very easy, exactly what I wanted, it fulfilled my need, the instructions and checklist were VERY helpful


Orlando,

FL

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Also I'm happy with this helpful tool regarding heath care!


Ashland,

MS

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Good investment!!!


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