Advance Health Care Directive

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Download California’s Advance Health Care Directive

You can download and print form to fill out with a pen, or save it to your computer and type into it. To save the completed form from a browser window, choose File > Save As and rename the file. Note: If you do not rename the file it WILL NOT save the information you enter.

Page-by-page Guide to California’s
Advance Health Care Directive

These pages provide tips and instruction for each page.

California Advance Health Care Directive cover

Advance Health Care Directive

You can download and print form to fill out with a pen, or save it to your computer and type into it.

Download the California Advance Health Care Directive now.

Share your Advance Health Care Directive with KP:

California Advance Health Care Directive page 1

Introduction – Page 1

1-ALearn more about our approach to Life Care Planning

1-BPlease remember to write these items on every page:

  • Your name.
  • Your medical record number, which is found on your blue Kaiser insurance card.

California Advance Health Care Directive page 2

Part 1 – My Health Care Agent – Page 2

2-AWhat are the qualities you should look for in agent? Learn how to choose an agent.

2-BLearn more about what is an agent and their responsibilities

2-CSome people don’t have anyone in mind to be their agent. Learn about Life Care Planning without an agent.

California Advance Health Care Directive page 3

Part 1 – My Health Care Agent – Page 3

3-AAn alternate agent would be needed if your primary agent is not available. Learn more about agents

3-BVideo: What I might consider when choosing my agent

California Advance Health Care Directive page 4

Part 1 – My Health Care Agent – Page 4

4-AThis space may be used for any instructions related to agents and their powers. If you have a family member who has beliefs about these topics that are significantly different from yours, you may decide to exclude this person from being involved in decision-making, even informally.

4-BLearn more about these situations.

California Advance Health Care Directive page 5

Part 2 – My Values – Page 5

5-AIn a serious medical situation, where the outcome is uncertain, your agent may look to this section for guidance. You’ll be doing your agent a favor by providing rich detail here.

5-BFor further guidance, read your values are at the center of your life care plan.

5-CSituations where values matter.

5-DIf you are part of a faith community, please add in details of how we may contact them.

California Advance Health Care Directive page 6

Part 3 – My Health Care Instructions – Page 6

6-AShould you ever be in a similar situation, it would be valuable for your agent to know your opinions about life sustaining treatment.

6-BVideo: Get more details about this brain injury scenario.

6-CVideo: Learn more accepting life sustaining treatments for a specific time period, in this scenario.

California Advance Health Care Directive page 7

Part 3 – My Health Care Instructions – Page 7

7-ACPR can save lives, but it’s not as effective most people think. Read a discussion about CPR.

California Advance Health Care Directive page 8

Part 4 – My Hopes and Wishes – Page 8

8-ASometimes, our values inform not only what we want, but of what we don’t want. If you have some thoughts about how you would ideally like to die, please add them here.

8-BIf you’re interested in organ donation, please be sure your agent is aware of this. Your agent would be responsible for arranging this at the time of death.

California Advance Health Care Directive page 9

Part 4 – Organ Donation, other wishes – Page 9

9-ABe aware that if you’re interested in whole body donation, this is typically arranged well in advance and requires forms and documentation.

California Advance Health Care Directive page 10

Part 5 – Making this document legally valid – Page 10

10-ALearn more about making this document legally valid.

10-BPlease note that a witness may not be your appointed health care agent. In addition remember:

  • At least one of your witnesses cannot be related to you (blood, marriage or adoption) and cannot be entitled to any part of your estate.
  • Neither witness can be your health care provider.

10-CSpecial witness requirement is only applicable if you are currently a patient in a skilled nursing facility.

California Advance Health Care Directive page 11

Part 5 – Making this document legally valid – Page 11

11-ALearn more about
making this document legally valid.

11-BPlease note that a witness may not also be a health care agent.

California Advance Health Care Directive page 12

Part 5 – Making this document legally valid – Page 12

12-AIf using a notary public, you’ll want to sign in their presence.

If you’re using witnesses, you’ll want to have your witnesses confirm that this is your signature. Or you may choose to sign in their presence.

12-BA notary public signature is only necessary if you don’t have witnesses. It is possible to skip the notary public and make this document valid with witnesses only.

California Advance Health Care Directive page 13

Part 6 – Next Steps – page 13

13-ALearn more about sharing your values with your agent.

13-BIf you have a scheduled appointment, you may hand deliver a copy to your doctor or you may call or visit your local Kaiser Permanente Health Education (Center for Healthy Living) department for questions or information on returning your Advance Health Care Directive.

Southern California members can send their completed Advance Health Care Directive to:
Central Scanning
1011 S East St
Anaheim, CA 92805

13-CRead more: With whom should you share your Life Care Plan?