DURABLE POWER OF ATTORNEY
FOR HEALTH CARE

With this Durable Power of Attorney for Health Care form, you can select someone to make health care decisions for you, if, for some reason you become unable to make those decisions yourself. You can also specify any wishes you may have about your health care, including your desires concerning decisions to withhold or remove life-sustaining treatment. A properly completed form provides the best legal protection available to help ensure that your wishes will be respected.

The Durable Power of Attorney for Health Care grants you, your agents and your treating physicians with special legal protections when following the wishes stated in this document.

REQUIREMENTS FOR VALIDITY

1. You must be a California resident who is at least 18 years old, of sound mind and acting of your own free will.

2. The individual(s) you select as your agent and alternate agents to make health care decisions for you must be at least 18 years old and must NOT be:

a. Your treating health care provider;

b. An employee of your treating health care provider, unless the employee is related to you by blood, marriage or adoption;

c. An operator of a community care facility or board and care home. (Community care facilities are sometimes called board and care homes. If you are unsure whether or not the person whom you wish to select operates a community care facility, you should ask that person.)

d. An employee of a community care facility or residential care facility for the elderly, unless the employee is related to you by blood, marriage or adoption.

3. You have talked with the individuals you have selected as your agent and alternate agents and those individuals have agreed to participate. (You may select someone who is not a California resident to act as your agent or alternate agent, but you should consider whether someone who lives far away will be available to make decisions for you, if, and when that may become necessary.)

4. You have read the instructions and completed sections 2, 6, 7, 8, 9, 10, and 11 to reflect your desires.

5. You have signed and dated this form.

6. You have had the form properly witnessed:

a. You have obtained the signatures of two adult witnesses who personally know you.

b. Neither witness is: (1) your agent or alternate agent designated in this form; (2) a health care provider, or the employee of a health care provider; (3) a person who operates or is employed by a community care facility or residential care facility for the elderly.

c. The witnesses are not related to you by blood, marriage, or adoption, and are not named in your will or so far as you know entitled to any part of your estate when you die.

7. You have given a copy of the completed form to those people, including your agent, family members and doctor, who may need this form in case an emergency requires a decision concerning your health care.

SPECIAL REQUIREMENTS

1. Patients in skilled nursing facilities must obtain the signature of a patient advocate or ombudsman. (If you are not sure whether you are in a skilled nursing facility, you should ask the people taking care of you.)

2. If you are a conservatee under the Lanterman-Petris-Short Act (California) and wish to select your conservator as your agent or alternate agent to make health care decisions, you must obtain a lawyer's certification. (If you are not sure whether the person you wish to select as your agent is your conservator under the Lanterman- Petris-Short Act, you should ask that person.)

IF YOU CHANGE YOUR MIND

In order to revoke all or a portion of this form, you will need to do the following: 1) Complete a new form with the changes you desire; 2) tell everyone who got a copy of the old form that it is no longer valid and ask that the copies of the old form be returned to you so you may destroy them; and 3) give copies of the new form to the people who may need the form to carry out your wishes as described above in number 7. If after reading this material, you still have unanswered questions, you should talk to your doctor or a lawyer.

WARNING TO PERSON EXECUTING THIS DOCUMENT

This is an important legal document which is authorized by the Keene Health Care Agent Act. Before executing this document you should know these important facts:

This document gives the person you designate as your agent (the attorney in fact) the power to make health care decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known.

Except as you otherwise specify in this document, this document gives your agent power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.

Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection, at the time, and health care necessary to keep you alive may not be stopped if you object at the time.

This document gives your agent authority to consent, to refuse to consent, and/or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. This power is subject to any statement of your desires and any limitations that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your agent to make health care decisions for you if your agent (1) authorizes anything that is illegal, (2) acts contrary to your known desires, or (3) where your desires are not known, does anything that is clearly contrary to your best interests.

Your agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document.

By law, your agent is not permitted to consent on your behalf to any of the following: commitment to or placement in a Mental Health Treatment Facility, convulsive treatment, psychosurgery, sterilization or abortion.

Unless you specify a shorter period in this document, this power will exist for seven years from the date you execute this document and, if you are unable to make health care decisions for yourself at the time when this seven year period ends, this power will continue to exist until the time when you become able to make health care decisions for yourself.

You have the right to revoke the authority of your agent by notifying your agent and your treating doctor, hospital, or other health care provider orally or in writing of the revocation.

Unless, you otherwise specify in this document, this document gives your agent the power after you die to: (1) authorize an autopsy, (2) donate your body or parts thereof for transplant for therapeutic or educational or scientific purposes, and (3) direct the disposition of your remains.

This document revokes any prior durable power of attorney for health care.

You should carefully read and follow the witnessing procedure described at the end of this document. This document will not be valid unless you comply with the witnessing procedure

If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.

Your agent may need this document immediately in case of an emergency that requires a decisions concerning your health care. Either keep this document where it is immediately available to your agent and alternate agents or give each of them an executed copy of this document. You may also want to give your doctor an executed copy of this document.

Do not use this form if you are a conservatee under the Lanterman-Petris-Short Act and you want to appoint your conservator as your agent. You can do that only if the appointment document includes a certificate of your attorney.

TERMS OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE

1. CREATION AND DURATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE.

By this document, I intend to create a power of attorney by appointing the person designated below to make health care decisions for me as allowed by Sections 2430 to 2443, inclusive, of the California Civil Code. This power of attorney is authorized by the Keene Health Care Agent Act and shall be construed in accordance with the provisions of Section 2500 to 2508, inclusive, of the California Civil Code. This power of attorney shall not be affected by my subsequent incapacity.

I understand that this Power of Attorney shall exist for seven years from the date of execution of this document unless I establish a shorter time period. If I am unable to make health care decisions for myself when this Power of Attorney expires, the authority I have granted my agent will continue to exist until the time when I become able to make health care decisions for myself.

(Optional) I wish to have this power of attorney for a period of time less than seven years after the date of execution, ending ___________________________

(Please insert names, addresses and telephone numbers in the appropriate blanks for yourself and your agent, alternate agents and/or conservator.)

2. DESIGNATION OF HEALTH CARE AGENT

(None of the following may be designated as your agent: (1) your treating health care provider, (2) a nonrelative employee of your treating health care provider, (3) an operator of a community care facility or residential care facility for the elderly, or (4) a nonrelative employee of an operator of a community care facility or residential care facility for the elderly.)

I,_____________________________________________________________________________

do hereby designate and appoint ___________________________________________________

______________________________________________________________________________

______________________________________________________________________________

as my attorney-in-fact (agent) to make health care decisions for me as authorized in this document. For the purposes of this document, "health care decision" means consent, refusal to consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat in an individual's physical or mental condition.

3. GENERAL STATEMENT OF AUTHORITY GRANTED

Subject to any limitations set forth in this document, I hereby grant my agent full power to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, including, but not limited to, my desires concerning obtaining, refusing or withdrawing life-prolonging care, treatment, services, and procedures.

(If you want to limit the authority of your agent to make health care decisions for you, you can state the limitations in section 6 ("Statement of Desires, Special Provisions, and Limitations") below. You can indicate your desires by including a statement of your desires in this same section.)

4. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH

Subject to and limitation in this document, my agent has the power and authority to do all of the following:

a. Request, review and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records.

b. Execute on my behalf and release or other docments that may be required in order to obtain this information.

c. Consent to the disclosure of this information.

(If you want to limit the authority of your agent to receive and disclose information relating to your health, you must state the limitation in section 6 ("Statement of Desires, Special Provisions, and Limitations") below.

5. SIGNING DOCUMENT, WAIVERS AND RELEASES

Where necessary to implement the health care decisions that my agent is authorized by this document to make, my agent has the power and authority to execute on my behalf all of the following:

a. Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advice."

b. Any necessary waiver or release from liability required by a hospital or physician.

(If you want to limit the authority of your agent to sign documents, waivers, and releases, you must state the limitation in section 6 ("Statement of Desires, Special Provisions, and Limitations") below.

6. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS

(Your agent must make health care decisions that are consistent with your known desires. You can, but are not required to, state your desires in the space provided below. You should consider whether you want to include a statement of your desires concerning life-prolonging care, treatment, services and procedures. You can also include a statement of your desires concerning other matters such as the consent to an autopsy, or the disposition of your remains. You can also make your desires known to your agent by discussing your desires with your agent or by some other means. If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limit in any way the authority given your agent by this document, you should state the limits in the space below. If you do not state any limits, your agent will have broad powers to make health care decisions for you, except to the extent that there are limits provided by law.)

I specifically express the following desires concerning these health care decisions:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

And I specifically limit this Durable Power of Attorney as follows:

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

(You may attach additional pages if you need more space to complete your statement. If you attach additional pages, you must date and sign EACH of the additional pages a the same time you date and sign this document.)

7. DESIGNATION OF AN ALTERNATE AGENT

(You are not required to designate any alternate agents but you may do so. Any alternate agent you designate will be able to make the same health care decisions as the agent designated in section 2, in the event that agent is unable or unwilling to act as your agent. Also, if the agent designated above is your spouse, his or her designation as your agent is automatically revoked by law if your marriage is dissolved.)

If the person designated in section 2 is not available and/or not willing to make a health care decision for me, then I designate the following person(s) to act as my agent(s) to make health care decisions for me as authorized in this document, such persons to serve in the order listed below:

A. First Alternate Agent:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

B. Second Alternate Agent:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

8. NOMINATION OF CONSERVATOR OF MY PERSON

(A conservator of the person may be appointed for you if a court decides that you are unable to properly care for your personal needs for physical health, food, clothing or shelter. The appointment of a conservator may affect, or transfer to the conservator your right to control your physical care, including under some circumstances your right to make health care decisions. You are not required to nominate a conservator but you may do so. The court will appoint the person you nominate, unless that would be contrary to your best interests. You may, but are not required to, nominate as your conservator the same person you name above as your health care agent. You can nominate an individual as your conservator by completing the space below.)

If a conservator of the person is to be appointed for me, I nominate the following individual to serve as conservator of the person:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

9. CONTRIBUTION OF ANATOMICAL GIFT

(If either statement reflects your desires, sign the box next to the statement. You do not have to sign either statement. If you do not sign either statement, you agent and your family will have the authority to make a gift of all or part of your body under the Uniform Anatomical Gift Act.)

______________________________ Pursuant to the Uniform Anatomical Signature Gift Act, I hereby give, effective upon my death:
 Signature
                                                        ______ Any needed organ or parts; or

                                                        ______ The parts or organs listed:

                                                        ___________________________________________

                                                        ___________________________________________

                                                        ___________________________________________

                                                        ___________________________________________

__________________________ I do no want to make a gift under the Signature Uniform Anatomical Gift Act, nor do I want my agent
 Signature                                or family to do so.

10. AUTOPSY

(If either statement reflects your desires, sign the box next to the statement. You do not have to sign either statement. If you do not sign either statement, your agent and your family will be able to authorize an autopsy.)

_________________________ I hereby consent to an examination of my body after my death to determine the cause of my death.
 Signature
________________________ My agent may not authorize an autopsy.
 Signature
 
 

11. DISPOSITION OF MY REMAINS

(If either statement reflects your desires, sign the box next to the statement. You do not have to sign either statement. If you do not sign either statement, your agent and your family will be able to direct the disposition of your remains.)

____________________ I prefer that my agent direct the disposition of my Signature remains by the following method:

                                        ___________ burial

                                        ___________ cremation

____________________ My agent may not direct the disposition of my remains Signature and I would prefer that (Please Name)

                                        ___________________________________________

                                        ___________________________________________

                                        direct the disposition of my remains.

____________________ I have directed the way I want my remains disposed of in a written contract for funeral services with
Signature
                                        ___________________________________________
                                                (Name of mortuary/cemetery)

                                        ___________ My will

                                        ___________ Other: _______________________

12. PRIOR DESIGNATIONS REVOKED

I revoke any prior durable power of attorney for health care.

SIGNATURE OF PRINCIPAL

I have personally executed this Durable Power of Attorney for Health Care document on ___________________ , 19 ___ at ______________________________________________.

___________________________________
Signature of Principal

(This power of attorney will not be valid unless it is signed by two qualified witnesses who are present when you sign or acknowledge your signature. If you have attached any additions pages to this form, you must date and sign each of the additional pages at the same time you date and sign this power of attorney.)

STATEMENT OF WITNESSES

(This document must be witnessed by two qualified witnesses. None of the following may be used as a witness: (1) a person you designate as your agent or alternate agent, (2) a health care provider, (3) an employee of a health care provider, (4) the operator of a community care facility, (5) an employee of an operator of a community care facility, (6) the operator of a residential care facility for the elderly, or (7) an employee of an operator of a residential care facility for the elderly. At least one of the witnesses must make the additional declaration set out on the next place.)

TO THE WITNESSES: Read Carefully before signing.

You can sign as a witness only if you personally know the principal or if the identity of the principal is proved to you by convincing evidence.

(To have convincing evidence of the identity of the principal, you must be presented with and reasonably rely on any one or more of the following:

a. An identification card or driver's license issued by the CaliforniaDepartment of Motor Vehicles that is current or has been issued within five years.

b. A passport issued by the Department of State of the United States that is current or has been issued within five years.

c. Any of the following documents if the document is current or has been issued within five years contains a photograph and description of the person named on it, is signed by the person and bears a serial or other identifying number:

1) A passport issued by a foreign government that has been stamped by the United States Immigration and Naturalization Service.

2) A driver's license issued by a state other than California or by a Canadian or Mexican public agency authorized to issue driver's licenses.

3) An identification card issued by a state other than California.

4) An identification card issued by any branch of the armed forces of the United States.

Other kinds of proof of identity are not allowed.)

I declare under penalty of perjury under the laws of California that the person who signed or acknowledged this document is personally known to me (or proved to me on the basis of convincing evidence) to be the principal, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as attorney in fact by this document, and that I am not a health care provider, an employee of a health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly.

Signature: ___________________________________

Residence Address: ____________________________

____________________________________________

Print Name: __________________________________

Date: _______________________________________
 
 
 
 

Signature: ___________________________________

Residence Address: ____________________________

____________________________________________

Print Name: __________________________________

Date: _______________________________________

(At least one of the above witnesses must also sign the following declaration.)

I further agree under penalty of perjury under the laws of California, that I am not related to the principal by blood, marriage, or adoption, and, to the best of me knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

___________________________                            ________________________________
Signature                                                                                      Signature

STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN

(If you are a patient in a skilled nursing facility, one of the witnesses must be a patient advocate or ombudsman. 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 both parts of the "Statement of Witnesses" above AND must also sign the following statement.)

I further 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 subdivision (f) of Section 2432 of the Civil Code.

______________________________________
Signature
 
 

STATEMENT OF LAWYER

(If you are a conservatee under the Lanterman-Petris-Short Act (of Division 5 of the Welfare and Institutions Code) and you wish to designate your conservator as your agent to make health care decisions, you must be represented by legal council. Your lawyer must also sign the following statement.)

I am a lawyer authorized to practice law in the state where this power of attorney was executed, and the principal was my client at the time this power of attorney was executed. I have advised my client concerning his or her rights in connection with this power of attorney and the applicable law and the consequences of signing or not signing the power of attorney, and my client, after being so advised, has executed this power of attorney.

Signature: ___________________________________

Residence Address: ____________________________

____________________________________________

Print Name: __________________________________

Date: _______________________________________

Your agent may need this document immediately in case of an emergency that requires a decision concerning your health care. You should keep the completed original document and give a copy of the completed original to your agent and any alternate agents. You should also give a copy to your doctor, members of your family, and any other people who would be likely to need a copy of this form to carry out your wishes.

Photocopies of this document can be relied upon as though they were originals.