California Advance Health Care Directive(Living Will) Form

The California advance health care directive(living will) is a document that outlines the instructions of any individual, of age, who would like to place into writing their specific wishes should the face any sort of end of life situation. The document will also allow a Principal to delegate their wishes regarding organ donation (if any) as well they shall have the ability to select a trusted Attorney in fact/Agent to oversee the instruction placed into the document to be certain that the medical team follows the instruction and would make close decisions if it would be impossible to carry out exact instructions. Once completed, the document must be signed by two witnesses in the presence of one another. This document may be revoked at any time as long as the Principal is of sound mind to do so.

Laws – Probate §4600 et seq. Natural Death Act

How to Write

Step 1 – The Principal must download the document and review all of the information at the beginning of the document. If the document requires clarification, they may wish to consult with an attorney to ensure that the have a clear understanding of what they are signing

Step 2 – Designation of Agent – The agent may be designated by providing the following information:

  • The selected agent’s full name
  • Address
  • City
  • State
  • Zip Code
  • Home Phone
  • Work Phone

Alternate Agent – (Optional) Enter the following information in the event the initial agent becomes unwilling or unable to serve or if revocation of the first agent should occur:

  • The alternate agent’s full name
  • Address
  • City
  • State
  • Zip Code
  • Home Phone
  • Work Phone

The Principal and Agents must review the remainder of the information contained in this section and make any additions in the lines (or add sheets if necessary) provided if needed:

  • Agent’s Authority
  • When Agent’s Authority Becomes Effective
  • Agent’s Obligation
  • Agent’s Post-death Authority

Step 2 – Nomination of Conservator – If the Principal completes this section they must understand that if there is any portion that they choose not to have included, they may strike through it

  • The Principal must check one of the selections in this area to indicate the specific instructions to their physicians

Pain Relief –

  • Enter any additional information with regard to pain alleviation if needed, in the lines provided

Other wishes –

  • If the Principal wishes to provide additional instructions, place them into the lines provided in this section – Add additional sheets if needed and attach to this document

Step 3 – Organ Donation –

  • Mark the applicable box preferred by the Principal
  • Check the box if organ donation will be allowed – strike any of the choices (1 through 4) that are not acceptable

Step 4 – Selection of Primary Care Physician- (Optional)

  • Enter the name of the Primary Care Physician
  • Address
  • City
  • State
  • Zip Code
  • Telephone number

Alternate Physician –

  • Enter the name of the Alternate Primary Care Physician
  • Address
  • City
  • State
  • Zip Code
  • Telephone number

Step 5 – Principal’s Signature and Information – Enter the following:

  • Print the Principal’s name
  • Principal’s Signature
  • Date of signature in mm/dd/yyyy
  • Address
  • City’
  • State
  • Zip Code

Step 6 – Witness Acknowledgement –

  • The Witnesses must carefully review the “Statement of Witness.” Once read and if in agreement the witnesses must provide all of the following (respectively):
  • Witnesses Printed Names
  • Addresses
  • City
  • State
  • Signature of each witness
  • Date of signature(s) mm/dd/yyyy format

Step 7 – Special Witness Requirement – These should only be completed if there are not two witnesses who have signed on behalf of the Principal’

  • Statement of Patient Advocate or Ombudsman
  • Printed name
  • Signature
  • Date of signature mm/dd/yyyy format
  • Address
  • City
  • State
  • Zip Code

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