California Medical Power of Attorney
This California Medical Power of Attorney is a legal document that allows you, the Principal, to designate a trusted person, known as your Agent, to make health care decisions on your behalf should you become unable to do so. This document is governed by the California Probate Code, Division 4.7 – Health Care Decisions, Sections 4600-4678.
Complete the following information to appoint your Health Care Agent:
Principal Information
Full Name: ___________________________
Address: ___________________________
___________________________
Date of Birth: ___________________________
Agent Information
Full Name: ___________________________
Address: ___________________________
___________________________
Primary Phone Number: ___________________________
Alternative Phone Number: ___________________________
Alternate Agent
If the primary Agent is unable or unwilling to act, an Alternate Agent can be named:
Full Name: ___________________________
Address: ___________________________
___________________________
Primary Phone Number: ___________________________
Alternative Phone Number: ___________________________
Authority of Agent
Your Agent will have the authority to make all health care decisions for you, including decisions regarding medical treatment, surgical procedures, life support, and access to medical records, among other things, in accordance with your wishes and under the laws of the State of California.
Special Instructions
You may specify any particular desires, limitations, or special instructions for your Agent:
__________________________________________________________________________
__________________________________________________________________________
Signatures
This document must be signed by the Principal, an ombudsman or patient advocate (if the Principal resides in a skilled nursing facility), and witnessed by two adults who are not named as an Agent or Alternate Agent.
Principal's Signature
Date: ___________________________
Signature: ___________________________
Ombudsman/Patient Advocate Signature (if applicable)
Date: ___________________________
Signature: ___________________________
Witnesses
-
Full Name: ___________________________
Signature: ___________________________
Date: ___________________________
-
Full Name: ___________________________
Signature: ___________________________
Date: ___________________________
Note: This document does not authorize anyone to make financial decisions on your behalf. A separate Power of Attorney for financial matters should be executed if you wish to grant such powers.