California Medical Power of Attorney Form

The California medical power of attorney form is  used to create an advance health care directive for the Principal. The other sections of this division govern the effect of the form or any other writing used to create an advance health care directive. An individual may complete or modify any/all or any part of the form in Section 4701. This form may be revoked at any time in writing and must be delivered to the Attorney(s) in Fact/Agent(s). (See California Probate Code Section 4700-4701)

How To Write

Step 1 – Begin by downloading the document and carefully reviewing all of the information on page one, so that you (the Principal) may better educate yourself and understand what your rights are. If at any point you are unsure about what is provided, you may consider consulting with a knowledgeable attorney to insure that all prepared instructions will always be followed in your best interest.

Step 2 – Designation of Agent – In this section , you, the principal, will designate someone you trust to act as your agent for your health care in the event you are no longer able to do so –

  • Enter the name of the person you would like to name as your healthcare decision maker (Agent)
  • Provide the physical address of your chosen agent
  • City
  • State
  • Zip Code
  • Home Telephone Number
  • Cell Telephone Number
  • Work Telephone Number

Step 2 – Optional designation of a second and third alternate Agent – In the event your named agent, is unable or unwilling to serve as your agent, you may wish to add another Attorney in Fact (Agent)

  • In the next two sections, you would enter the names of your alternate agents
  • The physical addresses of your alternates
  • City
  • State
  • Zip Codes
  • Home Telephone Numbers
  • Cell Phone Numbers
  • Work Telephone Numbers

Step 3 – Provide your Agent’s authority – Read the paragraph, add any additional specific information with regard to what you would like to allow your agent to decide with regard to your health care. If any of the information in the statement is not a part of your choices, strike through those duties for your agent

  • Specify to the best of your ability, exactly what your instructions are.
  • If you require more room, add a sheet continuing your instructions for your agent and attach them to this document

Step 4 – This section addresses –

  • When the authority becomes effective to the agent
  • The Agent’s obligations
  • Post death authority for your agent- in this section, you must state clearly if you choose to or not to donate anatomical gifts. Place these specific instructions into the lines provided. You do not have to allow any anatomical gifts to be provided if you choose not to.
  • Read “Nomination of Conservator” section which simply states that you are nominating any one of the three Agent’s you’ve named. If this is not the case, add a sheet with specific instructions as to exactly whom you would like to take over your person post death

Step 5 – End of Life Decisions – This section will ask that you make selections by checking any of the following –

  • 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
  • (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
  • (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 any additional wishes you would like recognized by your medical team and agent

Step 6 – Organ Donations at Death – mark your selection(s) as to what you would like to do with possible organ donation (if any)

  • Upon my death (mark applicable box):
  • (a) I give any needed organs, tissues, or parts
  • OR
  • (b) I give the following organs, tissues, or parts only:
  • My gift is for the following purposes (strike any of the following you do not want):
  • (1) Transplant
  • (2) Therapy
  • (3) Research
  • (4) Education

Step 6 – This step is optional, however, if you would like to designate specific physicians as your primary physicians you may do so in this area –

  • In designating a specific physician as your primary provide:
  • Name of the Physician
  • Physical address
  • City
  • State
  • Zip Code
  • Phone number
  • AND
  • Again this is optional – in the event the first primary physician is unable or unwilling to serve as your primary, you may name an alternate. Should you wish to name an alternate primary care physician provide –
  • Name of the alternate primary
  • Physical address
  • City
  • State
  • Zip Code
  • Telephone Number
  • You would then provide –
  • Printed name of the Principal
  • Your (Principal’s) signature
  • Date the section was signed
  • Physical address
  • City
  • State
  • Zip Code

Step 7 – You must have two witnesses who will sign this area of the document as well. The witnesses must read the paragraph provided. If in agreement, the witnesses must provide the following in the next two sections:

  • Printed Names
  • Signatures
  • Date Witnesses sign the form
  • Physical addresses
  • City
  • State
  • Zip Code
  • Telephone numbers

Step 8 – Special Witness Statement –  This section will apply if the Principal is placed in a skilled nursing facility. The patient advocate must read the section and provide the following:

  • Printed name of patient advocate
  • Signature of patient advocate
  • Date of signature
  • Physical address of patient advocate
  • City
  • State
  • Zip Code

Step 9 – Once the entire document is complete, make copies to be provided to all named on this document and any health care institutions or Doctors who may be involved in your health care decisions.