This California Medical Power of Attorney is a legal document that allows an individual (the "principal") to designate another person (the "agent") to make health care decisions on their behalf in the event they are unable to do so. It is crafted in accordance with the California Probate Code, specifically sections pertaining to durable powers of attorney for health care.
Principal Information
- Full Name: ___________________________
- Date of Birth: ________________________
- Address: _____________________________
- City: ___________ State: CA Zip: ________
- Phone Number: ________________________
Agent Information
- Full Name: ___________________________
- Relationship to Principal: ______________
- Address: _____________________________
- City: ___________ State: CA Zip: ________
- Alternate Phone Number: _______________
The principal designates the following agent to make health care decisions on their behalf:
_________________________________________
Alternate Agent Information (optional)
- Full Name: ___________________________
- Relationship to Principal: ______________
- Address: _____________________________
- City: ___________ State: CA Zip: ________
- Phone Number: ________________________
If the primary agent is unable, unwilling, or unavailable to serve, the principal designates the following alternate agent:
_________________________________________
General Authority Granted
The agent is given the authority to make all health care decisions for the principal, including but not limited to:
- Choosing or changing health care providers and institutions.
- Approving or denying diagnostic tests, surgical procedures, and medication plans.
- Access to medical records.
- Decisions regarding palliative care, including refusal or withdrawal of life-sustaining treatment.
These decisions can only be made when the principal is unable to do so, as determined by a medical professional.
Signatures
This document must be signed by the principal, the agent, and a witness or notary to be legally valid.
- Principal's Signature: ______________________ Date: _____________
- Agent's Signature: _________________________ Date: _____________
- Alternate Agent's Signature (if applicable): ______________________ Date: _____________
- Witness/Notary's Signature: ________________ Date: _____________