Free California Medical Power of Attorney Form

California combines the medical power of attorney and the living will into one advance health care directive. The power of attorney part names your agent, and the instructions part records your treatment wishes. The statutory form sits in Probate Code § 4701.

The execution rules are in Probate Code §§ 4673 to 4675.

Date and Sign the Directive

The directive must show the date you sign it. You can sign yourself, or another adult can sign your name in your presence and at your direction.

Choose Witnesses or a Notary

You can have the directive acknowledged before a notary public. Alternatively, have it signed by at least two qualified witnesses.

Who Cannot Be a Witness

Witnesses must be adults. None of these people may witness:

• Your health care provider, or an employee of your provider
• The operator or an employee of a community care facility
• The operator or an employee of a residential care facility for the elderly
• Your agent

Each witness also signs a declaration under penalty of perjury. It confirms they know you or verified your identity, and that you appeared of sound mind and free of pressure.

One Witness Must Be Unrelated

At least one witness cannot be related to you by blood, marriage, or adoption. That witness also cannot be entitled to part of your estate under an existing will.

You need a patient advocate or ombudsman as a witness. If you are a patient in a skilled nursing facility when you sign, your California medical power of attorney is not effective without one. They are designated by the California Department of Aging.

That witness can be one of your two witnesses. If you use a notary instead, the advocate or ombudsman still signs in addition to the notarization. California applies this rule because residents in custodial care need extra assurance that they are signing freely.

Here is how to finish your California medical power of attorney form:

1. Complete Part 1 to name your agent and any alternates.
2. Fill in your health care instructions, if you want to include them.
3. Decide between a notary and two qualified witnesses.
4. If you live in a skilled nursing facility, arrange for a patient advocate or ombudsman to witness.
5. Date and sign in front of the notary or your witnesses.
6. Keep the original safe and give copies to your agent and doctors.

You can use the statutory form or your own document that meets the signing rules. A complete California medical power of attorney usually covers:

• Your agent and any alternate agents
• Your health care instructions, if you want them in the same document
• An optional nomination of a conservator or guardian, which California law allows

Registering Is Optional

The California Secretary of State runs an Advance Health Care Directive Registry. You file a registration form with a copy of your directive attached, or list where the directive is kept instead. The information is released on request to your health care provider, a public guardian, or your legal representative, who must state why they need it.