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POWER OF ATTORNEY FOR HEALTH CARE
. DESIGNATION OF AGENT. I designate the following individual as my agent to make health-care decisions for me:
Agent:
| Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. AGENT'S AUTHORITY. My agent is authorized to make all health-care decisions for me, including decisions to provide, withhold or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive
. WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE. My agent's authority becomes effective when my primary physician determines that I am unable to make my own health-care decisions
. AGENT'S OBLIGATION. My agent shall make health-care decisions for me in accordance with this Healthcare Power of Attorney and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health-care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.
. EFFECT OF COPY. A copy of this form has the same effect as the original.
. SIGNATURE.
| Declarant Signature: | _______________________________________ |
| Name: |
| Address: |
| , |
| Date: | _____________________ |
NOTICE: SPECIAL RULES APPLY IF YOU ARE A RESIDENT OF A SKILLED NURSING FACILITY. IF YOU RESIDE IN SUCH A FACILITY, THIS DOCUMENT MUST BE SIGNED BY A PATIENT ADVOCATE OR OMBUDSMAN. IF YOUR DOCUMENT IS BEING WITNESSED BY TWO WITNESSES, ONE OF THOSE WITNESSES MUST BE THE ADVOCATE OR OMBUDSMAN WHO SIGNS ALL WITNESS STATEMENTS. IF YOUR DOCUMENT IS BEING NOTARIZED, THE ADVOCATE OR OMBUDSMAN MUST SIGN THE SPECIAL WITNESS REQUIREMENT SECTION.
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
. SPECIAL WITNESS REQUIREMENT.
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 the following statement:
STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN: I 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 Section 4675 of the Probate Code.
| Witness Signature: | ________________________________________ |
| Name: | ______________________________ |
| Address: | ______________________________ |
| City, State, Zip: | ______________________________ |
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It is quick and easy to grant or obtain the authority you need with a free California Medical Power of Attorney template from Rocket Lawyer:
This solution is, in most cases, notably less expensive than hiring a conventional attorney. If necessary, you can start a Medical PoA on behalf of a family member, and then have that person sign it when ready. Please remember that for a Power of Attorney to be accepted as valid, the principal must be mentally competent at the time of signing. If the principal has already been declared legally incompetent, a conservatorship might be required. In this scenario, it is important to speak to a lawyer .
Anyone who is over 18 years old ought to have a Medical Power of Attorney. Even though it's painful to acknowledge, there will likely come a time when you are not able to make important decisions on your own. Here are some common situations where you may find power of attorney to be helpful:
Regardless of whether your California Medical Power of Attorney is being created in response to an urgent issue or as part of a forward-looking plan, notarization and/or witnesses are strongly encouraged for protecting your document if someone disputes its lawfulness.
Sometimes, in researching the subjects of elder care and estate planning, you might see the terms "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" being used interchangeably. In reality, they are the same. That being said, please keep in mind that it's entirely possible to have agency over affairs that are not related to health care. In that case, "proxy" usually is not the term of choice.
California Medical PoA forms are usually easy to make, but you or your agent(s) might still have questions. It can depend on whom you contact, but quite often some lawyers will not even accept requests to review documents that they did not write. An easier approach to consider is to go through attorney services at Rocket Lawyer. With a Premium membership, you will be able to request guidance from an experienced attorney or send other legal questions about your Medical Power of Attorney. We're here for you.
The fees associated with finding and working with the average lawyer to produce a Medical Power of Attorney could total between two hundred and five hundred dollars, based on your location. Unlike most other Power of Attorney template websites that you might encounter, Rocket Lawyer provides Premium members up to 40% in savings when hiring a lawyer, so an attorney can take action on your behalf if you ever need help.
With a membership, you can edit it, download it as a Word or PDF file, and print it out. In order to complete your Power of Attorney, it will need to be signed. Your agent(s), care providers, and other impacted parties should receive a copy of your fully executed document.
The specific requirements and restrictions governing PoA forms will vary in each state; however, in California, your document must be signed by two witnesses or notarized. Witnesses to a Healthcare PoA should not be any employer or operator of the healthcare or community/residential care facility providing your care. Only one of the witnesses may be someone who is an heir, a beneficiary, or otherwise legally related to you (such as a spouse, adopted child, or family member). Finally, as a general principle, your witness(es) will need to be over 18 years old, and none of them should also be your Power of Attorney agent.
See California Medical/Healthcare Power of Attorney law: § 4680 - 4691
