California Durable Power of Attorney for Health Care Form


California Probate Code Section 4700-4701 permits you as signing principal to issue California POA Form for Health Care to grant powers to your agent to make health care decisions for you on your behalf as if you are making such decisions. You may choose to appoint alternate agent/s using a provision in this form. Please designate an agent using the first part of the form. The second part is reserved for advanced directives. Acknowledgement of two witnesses or notarization of this legal template is required for its execution. Please review instructions carefully and consult an attorney in case you do not understand any provision. You may choose to nominate a Conservator in this health care power of attorney in California State.

Health Care Durable Power of Attorney Form California Facts

  • The Ombudsman Program representative must sign as an additional witness in case you are preparing this California Health Care Durable POA in a nursing home.
  • Please select your priorities for powers to grant to make health care decisions for providing life sustaining procedures, organ donation after death, and any other limitation to grant powers.
  • Prepare this health care power of attorney in California State along with your agent and/or successor agent/s. Your agent must understand the agent’s obligations prior to accepting the responsibility of decision-making.
  • Both witnesses must sign this form in acknowledgement of your signature and identity. Please provide State ID in case witnesses do not know you personally. One of the witnesses must sign an additional declaration under penalty of perjury.

Directions for filling a Durable Health Care POA, California

Step 1: Enter your legal name on the first line and proceed to Part 1 by providing agent’s name, address, and phone numbers. Skip filling Part 1 in case you do not want to appoint an agent. Continue by providing name, address, and phone numbers for each alternate agent on separate lines.

Step 2: Sign with initials to provide instructions and express your desires to the agent. Then specify additional health care instructions, if any in the space provided for the same. You may nominate your agent as a conservator or strike out this portion of the Durable California Health Care POA Form otherwise.

Step 3: Sign before all applicable directives pertaining to provide the life sustaining procedures to you in Part 2. Specify other health care instructions if any on the succeeding lines. You may choose to revoke any previously issued health care power of attorney in California State.

Step 4: Date and sign before two witnesses / notary public of California State / Ombudsman program representative and ask them to sign on this form to acknowledge your signature and identity with signature and seal as applicable. One of the witnesses must sign the additional declaration under penalty of perjury.

Terminating a California Durable Health Care POA Form



This California Health Care Power of Attorney Form remains in force unless you cancel it personally by issuing duly signed and notarized instrument of cancellation. In addition, issuing a new health care power of attorney in California State cancels previously issued health care power of attorneys. However, please enclose a copy of power of attorney under termination along with this legal form for cancellation.