Advance Health Care Directive, California

PART 1
POWER OF ATTORNEY FOR HEALTH CARE

1.1       DESIGNATION OF HEALTH CARE 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)

__________________________________________________________
(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)

__________________________________________________________
(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)

__________________________________________________________
(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 ...