PROBATE CODE
SECTION 4700-4701




4700.  The form provided in Section 4701 may, but need not, be used
to create an advance health care directive. The other sections of
this division govern the effect of the form or any other writing used
to create an advance health care directive. An individual may
complete or modify all or any part of the form in Section 4701.




4701.  The statutory advance health care directive form is as
follows:
                          ADVANCE HEALTH CARE DIRECTIVE
                   (California Probate Code Section 4701)
                                 Explanation
   You have the right to give instructions about your own health
care. You also have the right to name someone else to make health
care decisions for you. This form lets you do either or both of these
things. It also lets you express your wishes regarding donation of
organs and the designation of your primary physician. If you use this
form, you may complete or modify all or any part of it. You are free
to use a different form.
   Part 1 of this form is a power of attorney for health care. Part 1
lets you name another individual as agent to make health care
decisions for you if you become incapable of making your own
decisions or if you want someone else to make those decisions for you
now even though you are still capable. You may also name an
alternate agent to act for you if your first choice is not willing,
able, or reasonably available to make decisions for you. (Your agent
may not be an operator or employee of a community care facility or a
residential care facility where you are receiving care, or your
supervising health care provider or employee of the health care
institution where you are receiving care, unless your agent is
related to you or is a coworker.)
   Unless the form you sign limits the authority of your agent, your
agent may make all health care decisions for you. This form has a
place for you to limit the authority of your agent. You need not
limit the authority of your agent if you wish to rely on your agent
for all health care decisions that may have to be made. If you choose
not to limit the authority of your agent, your agent will have the
right to:
   (a) Consent or refuse consent to any care, treatment, service, or
procedure to maintain, diagnose, or otherwise affect a physical or
mental condition.
   (b) Select or discharge health care providers and institutions.
   (c) Approve or disapprove diagnostic tests, surgical procedures,
and programs of medication.
   (d) Direct the provision, withholding, or withdrawal of artificial
nutrition and hydration and all other forms of health care,
including cardiopulmonary resuscitation.
   (e) Make anatomical gifts, authorize an autopsy, and direct
disposition of remains.
   Part 2 of this form lets you give specific instructions about any
aspect of your health care, whether or not you appoint an agent.
Choices are provided for you to express your wishes regarding the
provision, withholding, or withdrawal of treatment to keep you alive,
as well as the provision of pain relief. Space is also provided for
you to add to the choices you have made or for you to write out any
additional wishes. If you are satisfied to allow your agent to
determine what is best for you in making end-of-life decisions, you
need not fill out Part 2 of this form.
   Part 3 of this form lets you express an intention to donate your
bodily organs and tissues following your death.
   Part 4 of this form lets you designate a physician to have primary
responsibility for your health care.
   After completing this form, sign and date the form at the end. The
form must be signed by two qualified witnesses or acknowledged
before a notary public. Give a copy of the signed and completed form
to your physician, to any other health care providers you may have,
to any health care institution at which you are receiving care, and
to any health care agents you have named. You should talk to the
person you have named as agent to make sure that he or she
understands your wishes and is willing to take the responsibility.
   You have the right to revoke this advance health care directive or
replace this form at any time.

            * * * * * * * * * * * * * * * *
                         PART
                           1
           POWER OF ATTORNEY FOR HEALTH CARE
  (1.1) DESIGNATION OF AGENT: I designate the
  following individual as my agent to make health
  care decisions for me:
  __________________________________________________
       (name of individual you choose as agent)
  __________________________________________________
         (address)   (city)  (state) (ZIP Code)
  __________________________________________________
        (home phone)               (work phone)
  OPTIONAL: If I revoke my agent's authority or if
  my agent is not willing, able, or reasonably
  available to make a health care decision for me,
  I designate as my first alternate agent:
  __________________________________________________
   (name of individual you choose as first alternate
                        agent)
  __________________________________________________
         (address)   (city)  (state) (ZIP Code)
  __________________________________________________
        (home phone)               (work phone)
  OPTIONAL: 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:
  __________________________________________________
       (name of individual you choose as second
                   alternate agent)
  __________________________________________________
         (address)   (city)  (state) (ZIP Code)
  __________________________________________________
        (home phone)               (work phone)
  (1.2) 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,
  except as I state here:
  __________________________________________________
  __________________________________________________
  __________________________________________________
          (Add additional sheets if needed.)
  (1.3) 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     unless I
  mark the following box. If I mark this box ( ),
  my agent's authority to make health care
  decisions for me takes effect immediately.
  (1.4) AGENT'S OBLIGATION: My agent shall make
  health care decisions for me in accordance with
  this power of attorney for health care, any
  instructions I give in Part 2 of this form, 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.
  (1.5) AGENT'S POSTDEATH 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 Part 3 of this form:
  __________________________________________________
  __________________________________________________
  __________________________________________________
          (Add additional sheets if needed.)
  (1.6) NOMINATION OF CONSERVATOR: If a conservator
  of my person needs to be appointed for me by a
  court, I nominate the agent designated in this
  form. If that agent is not willing, able, or
  reasonably available     to act as conservator, I
  nominate the alternate agents whom I have named,
  in the order designated.
                         PART
                           2
             INSTRUCTIONS FOR HEALTH CARE
  If you fill out this part of the form, you may
  strike any wording you do not want.
  (2.1) 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:
  ( ) (a) 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, OR
  ( ) (b) Choice To Prolong Life
  I want my life to be prolonged as long as
  possible within the limits of generally accepted
  health care standards.
  (2.2) RELIEF FROM PAIN: Except as I state in the
  following space, I direct that treatment for
  alleviation of pain or discomfort be provided at
  all times, even if it hastens my death:
  __________________________________________________
  __________________________________________________
          (Add additional sheets if needed.)
  (2.3) 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.) I     direct that:
  __________________________________________________
  __________________________________________________
          (Add additional sheets if needed.)
                         PART
                           3
                 DONATION OF ORGANS AT
                         DEATH
                      (OPTIONAL)
  (3.1) Upon my death (mark applicable box):
  ( ) (a) I give any needed organs, tissues, or
  parts, OR
  ( ) (b) I give the following organs, tissues, or
  parts only.
  __________________________________________________
  (c) My gift is for the following purposes (strike
  any
  of
  the following you do not want):
  (1) Transplant
  (2) Therapy
  (3) Research
  (4) Education
                         PART
                           4
                        PRIMARY
                       PHYSICIAN
                      (OPTIONAL)
  (4.1) I designate the following physician as my
  primary physician:
  __________________________________________________
                  (name of physician)
  __________________________________________________
         (address)   (city)  (state) (ZIP Code)
  __________________________________________________
                        (phone)
  OPTIONAL: If the physician I have designated
  above is not willing, able, or reasonably
  available to act as my primary physician, I
  designate the following physician as my primary
  physician:
  __________________________________________________
                  (name of physician)
  __________________________________________________
         (address)   (city)  (state) (ZIP Code)
  __________________________________________________
                        (phone)
            * * * * * * * * * * * * * * * *
                        PART 5
  (5.1) EFFECT OF COPY: A copy of this form has the
  same effect as the original.
  (5.2) SIGNATURE: Sign and date the form here:
  _______________________    _______________________
           (date)                (sign your name)
  _______________________    _______________________
         (address)              (print your name)
  _______________________
     (city)     (state)
  (5.3) STATEMENT OF WITNESSES: I declare under
  penalty of perjury under the laws of California
  (1) 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, (2) that the individual
  signed or acknowledged this advance directive in
  my presence, (3) that the individual appears to
  be of sound mind and under no duress, fraud, or
  undue influence, (4) that I am not a person
  appointed as agent by this advance directive, and
  (5) 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              Second witness
  _______________________    _______________________
        (print name)               (print name)
  _______________________    _______________________
         (address)                  (address)
  _______________________    _______________________
      (city)   (state)           (city)   (state)
  _______________________    _______________________
   (signature of witness)     (signature of witness)
  _______________________    _______________________
           (date)                     (date)
  (5.4) ADDITIONAL STATEMENT OF     WITNESSES: At
  least one of the above witnesses must also sign
  the following
  declaration:
  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 of witness)     (signature of witness)
                         PART
                           6
              SPECIAL WITNESS REQUIREMENT
  (6.1) 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.
  _______________________    _______________________
           (date)                (sign your name)
  _______________________    _______________________
         (address)               (print your name)
  _______________________
      (city)   (state)