CALIFORNIA
Advance Directive

Planning for Important Health Care Decisions

USING THESE MATERIALS

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may receive health care.

2. These materials include:

• • Instructions for preparing your advance directive, please read all the instructions.
  • Your state-specific advance directive forms, which are the pages with the gray instruction bar on the left side.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so you will have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide you through the process.

3. Talk with your family, friends, and physicians about your advance directive. Be sure the person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy the form and give it to the person you have appointed to make decisions on your behalf, your family, friends, health care providers and/or faith leaders so that the form is available in the event of an emergency.

5. California maintains an Advance Directive Registry. By filing your advance directive with the registry, your health care provider and loved ones may be able to find a copy of your directive in the event you are unable to provide one. You can read more about the registry, including instructions on how to file your advance directive, at http://www.sos.ca.gov/registries/advance-health-care-directive-registry/

6. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

INTRODUCTION TO YOUR CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE

This packet contains a legal document, a California Advance Health Care Directive, that protects your right to refuse medical treatment you do not want, or to request treatment you do want, in the event you lose the ability to make decisions yourself. You may complete any or all of the first four parts, depending on your advance planning needs. You must complete part 5.

Part 1 is a Power of Attorney for Health Care. This part lets you name someone (an agent) to make decisions about your health care. Unless otherwise written in your advance directive, your power of attorney for health care becomes eective when your primary doctor determines that you lack the ability to understand the nature and consequences of your health care decisions or the ability to make and communicate your health care decisions. If you want your agent to make health care decisions for you now, even though you are still capable of making health care decisions, you can include this instruction in your power of attorney for health care designation.

Part 2 includes your Individual Instructions. This is your state’s living will. It lets you state your wishes about health care in the event that you can no longer speak for yourself and you may limit the individual instructions to take eect only if a specified condition arises.

Part 3 allows you to express your wishes regarding organ donation.

Part 4 of this form lets you designate a physician to have primary responsibility for your health care.

Part 5 contains the signature and witnessing provisions so that your document will be eective.

This form does not expressly address mental illness. If you would like to make advance care plans regarding mental illness, you should talk to your physician and an attorney about an advance directive tailored to your needs.
NOTE: These documents will be legally binding only if the person completing them is a competent adult, who is 18 years of age or older, or an emancipated minor.