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INTELLIGENT QUESTIONNAIRE FOR

CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE (LIVING WILL) - $16.95

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REQUIRED - PRINCIPAL'S INFORMATION  
   
NOTE: The questionnaire below assumes that it is being filled out by the Principal. Any uses of the words "I", "My", "You", or "Your" refer to the Principal that will sign the completed Advance Health Care Directive.
FAQ
Is An Advance Health Care Directive The Same As A Living Will?
 
First Name: Address:

Last Name:

City:  
    State: Zip:  
       
       
PART 1 - Power of Attorney for Health Care  
PART 1 is optional - Please select the checkbox if you want to prepare a Power of Attorney for Health Care, and keep it checked upon submission. If you do not wish to prepare this part, leave the checkbox unselected.
 
AGENT'S INFORMATION  
The Agent is the person who will act and make health care decisions for the Principal. The Agent must be an adult with CAPACITY!
             
IF YOU DO NOT KNOW WHO YOUR AGENT(S) WILL BE, YOU MAY LEAVE THE AGENT INFORMATION BLANK. THE FORM WILL PRINT WITH SPACES, WHICH YOU CAN FILL LATER BY HAND.
             
First Name: Address:  
Last Name: City:
Home Phone: - - State: Zip:  

Work Phone:

- -    
 
Will you appoint alternate Agents? If yes, how many?   
FAQ
Do I Need Alternate Agents?

First Alternate Agent:
First Name: Address:
Last Name: City:
Home Phone: - - State: Zip:  

Work Phone:

- -   

Second Alternate Agent:
First Name: Address:
Last Name: City:
Home Phone: - - State: Zip:  

Work Phone:

- -   
 
AGENT'S AUTHORITY  
 
Agent's Authority
Unless limited below, the agent is authorized to make all health care decisions for the Principal, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep the Principal alive.
FAQ
What Can or Can't My Agent Do?
 
 
Do you want to limit the Agent's authority?    
If yes, please state such limitations below:
Yes    No  
See Examples

When Agent's Authority Becomes Effective
Select one of the following statements:
My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions.
My agent's authority to make health care decisions for me takes effect immediately.


Agent's Postdeath Authority
Unless limited below, the agent will have authority to make anatomical gifts, authorize an autopsy, and direct disposition of the Principal's remains.

 
Do you want to limit the Agent's postdeath authority?
If yes, please state such limitations below:
Yes    No
 
See Examples
 
PART 2 - Instructions for Health Care  
PART 2 is optional - Please select the checkbox if you want to prepare Instructions for Health Care, and keep it checked upon submission. If you do not wish to prepare this part, leave the checkbox unselected.
 
End of Life Decisions
 
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: (select one of the following):

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.
CHOICE TO PROLONG LIFE: I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

   
Relief from Pain  
I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death, except as I state in the following space:
Do you have any exceptions to treatments for alleviation of pain or discomfort? If yes, please state such exceptions below: Yes    No  
FAQ
How Do I Make My Health Care Wishes Known?

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:
 
Do you have additional wishes?    
If yes, please state such wishes below:
Yes    No  
 
PART 3 - Donation of Organs at Death  
PART 3 is optional - Please select the checkbox if you want to donate organs at death, and keep it checked upon submission. If you do not wish to prepare this part, leave the checkbox unselected.
 
Upon my death (mark the applicable box)
FAQ
How Do I Donate Organs Upon Death?
I give any needed organs, tissues, or parts, OR
I give the following organs, tissues, or parts only (please type in the organs or body parts you would like to donate):
My gift is for the following purposes (uncheck the ones you do not want)
Transplant Therapy Research Education
 
PART 4 - Primary Physician  
PART 4 is optional - Please select the checkbox if you want to designate a Primary Physician, and keep it checked upon submission. If you do not wish to prepare this part, leave the checkbox unselected.
 
Primary Physician  
 
IF YOU DO NOT KNOW WHO YOUR PRIMARY PHYSICIAN(S) WILL BE, YOU MAY LEAVE THE PHYSICIAN INFORMATION BLANK. THE FORM WILL PRINT WITH SPACES, WHICH YOU CAN FILL LATER BY HAND.
   
I designate the following physician as my primary physician:
FAQ
Who Is My Primary Physician?
First Name: Address:
Last Name: City:
Phone: - - State: Zip:
 
Alternate Physician(OPTIONAL)
If the physician you have designated above is not willing, able, or reasonably available to act as your primary physician, would you like to designate an alternate physician?       Yes    No   
First Name: Address:
Last Name: City:
Phone: - - State: Zip:  
 
PART 5 - Signature and Witness  
PART 5 is required - In this part, you must sign and date the document. The final document must either be notarized or witnessed by two qualified witnesses.
 
Will you have your signature notarized or witnessed?
FAQ
What Is A Qualified Witness?
IF YOU DO NOT KNOW WHO YOUR WITNESSES WILL BE, YOU MAY LEAVE THE WITNESS INFORMATION BLANK AND ALLOW YOUR WITNESSES WO HANDWRITE THEIR INFORMATION LATER.
 
1st Witness Information:
First Name: Address:
Last Name: City:
Phone: - - State: Zip:  
 
2nd Witness Information:
First Name: Address:
Last Name: City:
Phone: - - State: Zip:
 
PART 6  
PART 6 is required
  
Are you a patient in a skilled nursing facility?      Yes No
FAQ
What Is A Skilled Nursing Facility? 
 
Name of Patient Advocate or Ombudsman:
First Name: Address:
Last Name: City:
Phone: - - State: Zip:
 
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