Source: https://www.1stoplegalforms.com/FormQs/FQ_0002.asp?Page_ID=3
Timestamp: 2017-03-23 20:05:57
Document Index: 1930763

Matched Legal Cases: ['ART 1', 'ART 1', 'ART 2', 'ART 2', 'ART 3', 'ART 3', 'ART 4', 'ART 4', 'ART 5', 'ART 5', 'ART 6', 'ART 6']

1Stop Legal Forms - Health Care Power of Attorney and Advance Directive
HOME | LOGIN | MYFORMS | FAQ INTELLIGENT QUESTIONNAIRE FOR CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE (LIVING WILL) - $16.95
REQUIRED - PRINCIPAL'S INFORMATION NOTE: The questionnaire below assumes that it is being filled out by the Principal. Any uses of the words "I", "My", "You", or "Your" refer to the Principal that will sign the completed Advance Health Care Directive.
Zip: PART 1 - Power of Attorney for Health Care PART 1 is optional - Please select the checkbox if you want to prepare a Power of Attorney for Health Care, and keep it checked upon submission. If you do not wish to prepare this part, leave the checkbox unselected. AGENT'S INFORMATION The Agent is the person who will act and make health care decisions for the Principal. The Agent must be an adult with CAPACITY!
Zip: Work Phone: - - Will you appoint alternate Agents? If yes, how many? None
First Alternate Agent: First Name: Address: Last Name: City: Home Phone: - - State: __
AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: Work Phone: - - Second Alternate Agent: First Name: Address: Last Name: City: Home Phone: - - State: __ AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: Work Phone: - - AGENT'S AUTHORITY Agent's Authority Unless limited below, the agent is authorized to make all health care decisions for the Principal, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep the Principal alive. FAQ What Can or Can't My Agent Do?
Do you want to limit the Agent's authority? If yes, please state such limitations below: Yes No See Examples When Agent's Authority Becomes Effective Select one of the following statements: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions. My agent's authority to make health care decisions for me takes effect immediately. Agent's Postdeath Authority Unless limited below, the agent will have authority to make anatomical gifts, authorize an autopsy, and direct disposition of the Principal's remains. Do you want to limit the Agent's postdeath authority? If yes, please state such limitations below: Yes No See Examples PART 2 - Instructions for Health Care PART 2 is optional - Please select the checkbox if you want to prepare Instructions for Health Care, and keep it checked upon submission. If you do not wish to prepare this part, leave the checkbox unselected. 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: (select one of the following):
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.
CHOICE TO PROLONG LIFE: I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death, except as I state in the following space:
Do you have any exceptions to treatments for alleviation of pain or discomfort? If yes, please state such exceptions below: Yes No
How Do I Make My Health Care Wishes Known?
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:
Do you have additional wishes? If yes, please state such wishes below: Yes No PART 3 - Donation of Organs at Death PART 3 is optional - Please select the checkbox if you want to donate organs at death, and keep it checked upon submission. If you do not wish to prepare this part, leave the checkbox unselected. Upon my death (mark the applicable box) FAQ
I give any needed organs, tissues, or parts, OR
I give the following organs, tissues, or parts only (please type in the organs or body parts you would like to donate): My gift is for the following purposes (uncheck the ones you do not want)
Transplant Therapy Research Education PART 4 - Primary Physician PART 4 is optional - Please select the checkbox if you want to designate a Primary Physician, and keep it checked upon submission. If you do not wish to prepare this part, leave the checkbox unselected. Primary Physician
IF YOU DO NOT KNOW WHO YOUR PRIMARY PHYSICIAN(S) WILL BE, YOU MAY LEAVE THE PHYSICIAN INFORMATION BLANK. THE FORM WILL PRINT WITH SPACES, WHICH YOU CAN FILL LATER BY HAND.
Phone: - - State:
__ AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: Alternate Physician(OPTIONAL)
If the physician you have designated above is not willing, able, or reasonably available to act as your primary physician, would you like to designate an alternate physician? Yes No First Name: Address: Last Name: City: Phone: - - State:
__ AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: PART 5 - Signature and Witness PART 5 is required - In this part, you must sign and date the document. The final document must either be notarized or witnessed by two qualified witnesses. Will you have your signature notarized or witnessed? Notarized Witnessed FAQ
IF YOU DO NOT KNOW WHO YOUR WITNESSES WILL BE, YOU MAY LEAVE THE WITNESS INFORMATION BLANK AND ALLOW YOUR WITNESSES WO HANDWRITE THEIR INFORMATION LATER.
1st Witness Information: First Name: Address: Last Name: City: Phone: - - State: __ AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: 2nd Witness Information: First Name: Address: Last Name: City: Phone: - - State: __ AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: PART 6 PART 6 is required Are you a patient in a skilled nursing facility? Yes No FAQ
What Is A Skilled Nursing Facility? Name of Patient Advocate or Ombudsman: First Name: Address: Last Name: City: Phone: - - State: CA Zip: To clear the formIf you want to complete the form laterIf the form is complete; go to check out SSL Certificate