Note that whenever the term "Advance Health Care Directive" is used it refers to the statements made by an individual regarding medical care in the event of incapacity. A document prepared containing an individual's instructions regarding medical care is properly labled an "Advance Health Care Directive" and may name another individual as an agent to make such decisions in the event of incapacity. The named individual is the person's agent. The appointment of the agent is the "Durable Power of Attorney for Health Care." Therefore, although an Advance Health Care Directive document may also create a Durable Power of Attorney for Health Care, it need not do so.

Effective July 1, 2000, California's new "Advance Health Care Directive" replaces the Statutory form Durable Power of Attorney for Health Care. Under the statute (Probate Code Section 4701), an Advance Health Care Directive allows more flexibility in expressing one's desires concerning medical care and the continuation of life-sustaining treatment than the previous statutory form "Durable Power of Attorney for Health Care." Although papers prepared on or after July 1, 2000 must comply with the new law, documents properly drafted under the law in effect prior to July 1, 2000 will remain valid and enforceable.

In general, a "Power of Attorney" allows an individual (the "principal") to name an agent (also known as an "attorney-in-fact") to act on behalf of the principal when the principal cannot act on his or her own. A separate form is required for an agent to obtain the legal authority to act as a power of attorney for financial matters and a separate form is required for an agent to act as the power of attorney for health care (contained in an "Advance Health Care Directive" document).

Note: The information on this page can be used for preparing Advance Health Care Directive and Power of Attorney documents for you. Completed information on the form below will NOT operate as a Power of Attorney or Advance Health Care Diretive for any purposes.

Uniform Statutory Power of Attorney for Financial Matters (DPAF)

The California Statutory Form Power of Attorney (Probate Code §4401) allows a principal to grant an agent authority to conduct transactions involving financial decision making. You may name more than one agent, and you may require that they act either separately or jointly. The powers granted your agent(s) are broad and sweeping, but may be limited or expanded by the principal with some exceptions imposed by law. The DPAF may continue in full force and effect even if you become incapacitated provided the proper language is included in the form.

The Uniform Statutory Form Power of Attorney for Financial Matters must be signed by the principal, dated and acknowledged by a notary public (Probate Code § 4402(c)).

Special Power of Attorney Applicable to Accounts with Financial Institutions

Although your Power of Attorney form for Financial Matters provides your agent with the necessary legal authority to engage in transactions for the benefit of the principal, many banks and other financial institutions may ask for a power of attorney form prepared in their own format for accounts maintained by the principal at a particular financial institution. California Probate Code §5204 specifically addresses this situation.

For a Special Power of Attorney for Financial Institutions to be effective, it must explicitly identify the agent, the financial institution, and the accounts or contracts subject to the power of attorney.

If you have any questions regarding a Special Power of Attorney for Financial Institutions, consult your attorney before signing.

Advance Health Care Directive:

An Advance Health Care Directive allows an individual to state his or her desires with respect to medical care and life sustaining treatment in the event the individual is uable to make such decisions on his or her own. An individual may name a power of attorney (agent) to act on his or her beahlf in the event of incapacity. Specific desires and intentions may be stated with respect to the extent of life sustaining treatment that may be used. Alternate agents may be named in the event the primary agent is unable or unwilling to exercise his or her authority. The Advance Health Care Directive and Power of Attorney for Health Care will continue indefinitely unless an expriation date is stated.

A great benefit of establishing a Durable Power of Attorney for Financial Matters and for Health Care is the elimination of the need for a court-appointed conservator in the event of incapacity. Without a duly appoint agent available to act on behalf of an incapacitated person, most decisions relating to financial matters and health care cannot be made until a court has appointed a conservator. A conservatorship proceeding can be very involved and technical compared to the simplicity of granting a trusted person power of attorney.

The Advance Health Care Directive may be signed before at least two (2) witnesses, or may be signed before a notary public. (See below for special requirements regarding witnesses).

Advance Health Care Directive Witness Requirements:

Witnesses to an Advance Health Care Directive must meet the following requirements: (1) not the principal's health care provider, nor an employee of the principal's health care provider; (2) not the operator or an employee of a community care facility; (3) not the operator or an employee of a residential care facility for the elderly. In addition, at least one witness must not be a relative of the principal; at least one witness must be an individual who would not inherit from the principal either by will or intestacy; and if the principal is a patient in a skilled nursing facility, then at least one witness must be a patient advocate/ombudsman. The patient advocate/ombudsman may witness as an additional (third) witness.

Some Information for Completing the Forms:

I. Statutory Durable Power of Attorney for Financial Matters (DPAF).

Your Name:

Your Address:

Your Telephone Number: Home:

Business:

Your social security number:

Name(s) and Address(es) of Agent(s) for Financial Matters:

Powers Granted/Withheld

You may specifically authorize or withhold power from your agent in the following areas. Please initial next to each power you wish to authorize your agent to have. Cross out each power you wish to withhold:

INITIAL

(A) Real property transactions.

(B) Tangible personal property transactions.

(C) Stock and bond transactions.

(D) Commodity and option transactions.

(E) Banking and other financial institution transactions.

(F) Business operating transactions.

(G) Insurance and annuity transactions.

(H) Estate, trust, and other beneficiary transactions.

(I) Claims and litigation.

(J) Personal and family maintenance.

(K) Benefits from social security, Medicare, Medicaid, or other governmental programs, or civil or military service.

(L) Retirement plan transactions.

(M) Tax matters.

(N) ALL OF THE POWERS LISTED ABOVE.

Are there any special instructions you wish to give your agent? You may limit or extend the powers described above, with the limitation that by law you may not authorize your agent to create, modify, or revoke a trust, fund a trust with your property (except your own trust as you may direct), make or revoke a gift of your property, disclaim an interest on the principal's behalf without court approval, alter or create survivorship interests, or make a loan to the agent.

If you have designated more than one agent, how do you authorize them to act? Indicate either separately or jointly:

Separately Jointly

II. Advance Health Care Directive:

Name, Address, and telephone number of Health Care Agent:

In deciding the extent of treatment you wish to receive in the event of incapacity, you may wish to consider that three alternative statements have been used generally to express the level of treatment desired. The wording that is ultimately used is by no means limited to these three choices:

1. I do not want my life   2. I want my life to be     3. I want my life to be    
to be prolonged and I do   prolonged and I want        prolonged to the greatest  
not want life-sustaining   life-sustaining treatment   extent possible without    
treatment to be provided   to be provided unless I am  regard to my condition,    
or continued if the        in a coma which my doctors  the chances I have for     
burdens of the treatment   reasonably believe to be    recovery or the cost of    
outweigh the expected      irreversible.  Once my      the procedures.            
benefits.  I want my       doctors have reasonably                                
agent to consider the      concluded I am in an                                   
relief of suffering and    irreversible coma, I do                                
the quality as well as     not want life-sustaining                               
the extent of the          treatment to be provided                               
possible extension of my   or continued.                                          
life in making decisions                                                          
concerning                                                                        
life-sustaining                                                                   
treatment.                                                                        

Please state your desires with respect to life-prolonging care, treatment, services and procedures below. Be as specific as possible. Consider stating with whom your agent should consult, and the names and addresses of your doctors. You should express your wishes regarding artificial nutrition and hydration here. You may refer to, and/or modify any of the above three choices in stating your wishes:

If you wish your Advance Health Care Directive to expire at some time in the future, please state the date at which you wish it to expire. If you do not specify a date, it will continue to be in effect indefinitely:

Are there any other special powers or restrictions you wish to request of your agent? You may also wish to consider whether you authorize your agent to make an anatomical gift upon your death, (organ donation), whether you wish to authorize or withhold your agent's right to decide on whether an autopsy may be performed, or whether your agent may decide how to dispose of your remains. If you state no special wishes, your agent will be given authority to make all of the decisions described in this paragraph.

Name, address and telephone number of First Alternate Agent:

Name, address and telephone number of Second Alternate Agent:

Who do you nominate to serve as conservator in the event it becomes necessary for a court to appoint a conservator for you?

Name and address of conservator nominee:

If you wish this office to consider representing you in connection with preparation of a Durable Power of Attorney, or Advance Health Care Directive, please return this completed form to this office for consideration.

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