California · Reviewed source record · No account
Your California healthcare proxy worksheet
Prepare names and contact details privately in this browser, then transfer them to the state-published form. This worksheet is not a legal document and should not be signed.
Need the basics first? Read what a healthcare proxy does →
Direct answer · reviewed record CA
Which form does California use?
California calls this document the Advance Health Care Directive. California does not require a particular form; the Department of Justice publishes this statutory sample form.
Signing summary: Use the form's acknowledgment before a notary or sign before two qualified witnesses. The sample form provides an acknowledgment for a notary as an alternative to its two-witness section. Skilled nursing facility: A patient advocate or ombudsman must sign the form's special witness statement.
Source & freshness ledger
What was checked
This static page was checked on the source and editorial review dates shown. The build blocks an overdue record from future publication, but a deployed copy cannot remove itself. Always confirm the current instructions on the issuing authority's site before signing.
- Publication status
- Reviewed for publication
- Issuing authority
- California Department of Justice: Advance Care Planning
- Form reviewed
- Advance Health Care Directive Form · Statutory form text amended effective January 1, 2019
- Source checked
- Editorial review
- by MedicalRecords.com Editorial
- Review due
- Review owner
- MedicalRecords.com Editorial Operations
Execution details captured from the reviewed form
- Witnesses
- Use the form's acknowledgment before a notary or sign before two qualified witnesses.
- A witness cannot be the agent appointed in the directive.
- A witness cannot be the supervising health care provider, that provider's employee, or an operator or employee of a community care or residential care facility for the elderly.
- At least one witness must be unrelated by blood, marriage, or adoption and not entitled to any part of the person's estate.
- Notary
- The sample form provides an acknowledgment for a notary as an alternative to its two-witness section.
- Special facility rule
- Skilled nursing facility: A patient advocate or ombudsman must sign the form's special witness statement.
- Authority
- Signer
- Principal
- Advocate
Start with the governing form
Free, no account, no payment. We only continue when the official state form has passed source review.
In California, the reviewed document is the Advance Health Care Directive.
Signing summary: Use the form's acknowledgment before a notary or sign before two qualified witnesses. The sample form provides an acknowledgment for a notary as an alternative to its two-witness section.
Skilled nursing facility: A patient advocate or ombudsman must sign the form's special witness statement.
Official source checked August 11, 2026