Advance Directive For Health Care (Page 6 of 7) in pdf

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS AND REHABILITATION

ADVANCE DIRECTIVE FOR HEALTH CARE

CDCR 7421 (REV. 09/09)

Signature of Patient-Inmate: Sign and date form here:

(Print your Name)

(Institution)

(City)

(State)

(Current Housing)

(Signature)

(Date)

Statement of Witnesses

“I declare under penalty of perjury under the laws of California (1) that the individual who signed or acknowledged this

advance health care directive is personally known to me, or that the individual’s identity was proven to me by convincing

evidence, (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the individual

appears to be of sound mind and under no duress, fraud or undue influence, (4) that I am not a person appointed as an

agent by this advance directive, and (5) that I am not the individual’s health care provider, an employee of the

individual’s health care provider, the operator of a community care facility, an employee of an operator of a community

care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care

facility for the elderly.”

•

One witness may be a family member if available, but at least one witness must be someone who is

not related to the patient-inmate. (witness 2)

•

Correctional Staff, other CDCR employees or medical staff not directly involved with the care of this

patient may act as witnesses to the patient’s signature.

•

As above, your agent may not be a witness.

Witness 1 Signature:

Full Printed Name:

Title:

Date:

“I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this advance

health care directive by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the individual’s

estate upon his or her death under a will now existing or by operation of law.”

Witness 2 Signature:

Full Printed Name:

Title:

Date:

Notary: In unusual circumstances a notary may be used to verify the signature of the patient-inmate.

If so, please see page 7.

Distribution: Original-UHR, Copy to Inmate

Page 6 of 7

Advance Directive For Health Care Page 6