1.3 Second Alternate Appointment. If I revoke the authority of my agent and first alternate agent or
if neither is willing, able, or reasonably
available to make a health care decision for me, I designate as my second
alternate agent:
|
Print
Name: Home Phone: Work Phone: Cell Phone: |
|
Relationship: Mailing
Address: |
|
|
|
|
||
|
|
E-Mail Address: |
|
|
|
|
|
|
1.4 Agent’s Authority. My agent is
authorized to make all health care decisions for me, including decisions to provide, withhold or withdraw medical treatment to
keep me alive, except as I state in Part 2 below.
1.5 When Agent’s
Authority Becomes Effective. My agent’s authority becomes effective when my
primary physiccian determines that I am unable to make my own health
care decisions.
1.6 Agent’s Obligation. My agent shall make health care decisions for me in accordance
with (i) this power of attorney for health care, (ii) any instructions I give in Part 2 of this
form, and (iii) 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.
1.7. Agent’s Post-Death Authority. My agent is authorized to
make anatomical gifts, authorize an autopsy, and direct
disposition of my remains, except as I state here or in Parts
3 and 4 of this form:
Part 2 – INSTRUCTIONS FOR HEALTH CARE
2.1 Health Care Decisions Should Be Consistent With Catholic Teaching. Any decision concerning my
health care
should be consistent with relevant teachings of the
Roman Catholic Church. Those teachings are summarized on the first page of this
Advance Health Care Directive.
2.2 End-Of-Life Decisions. It is impossible to
adequately anticipate all the considerations which must be weighed at
the time when a decision concerning life-sustaining
treatment is to be made. Therefore, if I have appointed an agent in Part 1
above, I have full confidence in the judgment of that person, and I request
that my health care providers follow his or her instructions.
2.3 Special Instructions (Optional). The following lines may be
used to set forth any further directions, limitations,
or statements concerning health care, treatment, services
and procedures:
Part 3 – DONATION OF ORGANS (OPTIONAL)
The agent designated in this document has the authority to make
anatomical gifts unless contrary intentions have been expressed. In order to
clearly express your intentions, check (a) or (b) and use blank spaces for any
limitations:
(a)
I do not wish to donate
any of my organs, tissues or parts upon my death.
(b)
I give
any needed organs, tissues, or parts,
OR – My
gift is limited to the following organs, tissues or parts only:
My gift is for the following purposes (cross out any of
the following you do not want):
(1) Transplant (2) Therapy (3) Research (4) Education
Other limitations:
Part 4 – DISPOSITION
OF REMAINS (OPTIONAL)
4.1 Agent’s Authority. I understand that my agent designated in this
document has the authority to dispose of my remains unless I otherwise
provide, in writing.
4.2 Instructions. My instructions for the disposition of my remains
are described in:
(a)
A
written contract for funeral services with:
Name of Funeral Director, Mortuary and/or Cemetery
(b)
My will,
which I keep:
Location of Will
(c)
Instructions as follows:
Specific Instructions
Part 5 – HIPAA DISCLOSURE AUTHORIZATION
5.1 Authorized Disclosures
of Medical Information. I hereby grant to each of the individuals named as my primary
and alternative health care agents in Part 1 of this
document full power and authority to request, review and receive any
information, verbal or written, regarding my physical or mental health, to the
same extent that I myself would have such rights under the Health Insurance
Portability and Accountability Act of 1996. I further grant to each of said
individuals the further right to consent to the disclosure of such information
to third parties.
5.2 HIPAA Authorization Effective Immediately. The foregoing
authorizations are effective immediately and, not‑
withstanding the
provisions of Section 1.5 above, are not contingent on my own inability to make
health care decisions.
Part 6 – REVOCATION
OF PRIOR DIRECTIVES
6.1 Revocation of Prior Appointments of
Health Care Agents. By execution of this document, I hereby revoke all
prior Powers of Attorney for Health Care and any and all other
appointments of health care agents under the laws of any jurisdiction within or
without the United States of America.
6.2 Revocation of
Prior Health Care Directives. By execution of this document, I hereby revoke all
prior documents,
wherever executed within or without the United States of America, which
would be deemed to function as an Advance Health Care Directive under the laws
of the State of California.
Part 7 – SIGNATURE
AND WITNESSES
7.1 Effect of Copy. A copy of this form has the same effect as the
original.
7.2 Signature and Date.
Date of Signature:
(sign your name)
Place
of Signature:
7.3 Statement of Witnesses. I declare under penalty of
perjury under the laws of California (i) that the
individual who signed or acknowledged this
advance health care directive is personally known to me, or that the
individual’s identity was proven to me by convincing evidence (ii) that the
individual signed or acknowledged this advance directive in my presence, (iii)
that the individual appears to be of sound mind and under no duress, fraud, or
undue influence, (iv) that I am not a person appointed as agent by this advance
directive, and (v) that I am not the individual’s health care provider, an employee
of the individual’s health care provider, the operator of a community care
facility, an employee of an operator of a community care facility, the operator
of a residential care facility for the elderly, nor an employee of an operator
of a residential care facility for the elderly.
First Witness: Address:
|
|
|
(signature) |
|
|
||
|
|
|
|
|
|
||
|
(date) (printed name) |
|
|
|
|||
|
Second
Witness: Address: |
|
|||||
|
|
|
|
(signature) |
|
|
|
|
(date) (printed name) |
|
|
|
|||
7.4 Additional Witness Statement. At
least one of the above witnesses must also sign a declaration as follows:
I further declare under penalty of perjury under the laws of California
that I am not related to the individual executing this advance health care
directive by blood, marriage, or adoption, and to the best of my knowledge, I
am not entitled to any part of the individual’s estate upon his or her death
under a will now existing or by operation of law.
(signature) (signature)
Part 8 – ACKNOWLEDGMENT
BEFORE NOTARY PUBLIC
8.1 Notary Public
Acknowledgment As Alternative To Witnesses In Part 7. Acknowledgment before a
Notary Public is not required if properly
witnessed in Part 7 above. Acknowledgment before a Notary Public does not
eliminate the need for the Statement of a Patient Advocate or Ombudsman, in Part 9
below, which is required for patients in skilled nursing facilities.
STATE OF CALIFORNIA )
) ss
COUNTY OF )
On , 20___, before me, the
undersigned , a notary
public for the State of California, personally appeared , personally known to me, or proved to me on
the basis of satisfactory evidence, to be the person whose name is subscribed
to the within instrument and acknowledged that he or she executed the same in
his or her authorized capacity, and that by his or her signature on the
instrument the person, or the entity upon behalf of which the person acted,
executed the instrument.
IN WITNESS WHEREOF, I have hereunto set my hand and
affixed my official seal the day and year first above
written.
Notary
Public
[Seal]