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Kaiser Health Care Directives Form

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE

Including Power of Attorney for Health Care Imprint / MRN

NOTE: The document meets legal requirements for most Californians, but might not be appropriate in special circumstances. If you might have special needs, consult an attorney.

PART 1: APPOINTING AN AGENT TO MAKE HEALTH CARE DECISIONS

NOTE: You should discuss your wishes in detail with your designated agent(s)

My name is:   Date of Birth:

My address is:

In this document I appoint an agent. That agent will make health care decisions for me in the future, if and when I no longer have the mental capacity to make my own health care decisions.

Optional: I want my agent to make my health care decisions now, even though I currently have the mental capacity to make my own health care decisions. (Do not initial here if you want to continue making your own health decisions for as long as you are able.)

The following persons cannot be selected as your agent or alternate agent:

• Your primary physician

• An employee of the health care institution or residential care facility where you receive care (unless you are related to that person or you are co-workers).

PRIMARY AGENT:

Agent’s Name:

Address:

Phone numbers – indicate home, work, pager, and cellular phone:

1st ALTERNATE AGENT (If Agent is not willing, able, or reasonably available to serve.)

Name of first alternate agent:

Address:

Phone numbers – indicate home, work, pager, and cellular phone:

2nd ALTERNATE AGENT (If Agent and 1st Alternate are unavailable or unwilling to serve.)

Name of second alternate agent:

Address:

Phone numbers – indicate home, work, pager, and cellular phone:

WHAT MY AGENT MAY DO

My agent will be allowed to make health care decisions for me just as I can presently make my own. For example, I give my agent my trust to make decisions (1) to accept or refuse treatment for me, including accepting or discontinuing food and fluid that is given through a tube into my stomach or into a vein; (2) to choose for me a particular physician or health care facility; and (3) to receive or review my medical information and records, or to permit release of my records for others’ review. (initial here)

WHAT MY AGENT MUST DO

My agent shall make health care decisions for me by considering what I have written here, and by considering my other wishes. My agent will try to find out as much as he/she can about my wishes. If my agent does not know my wishes, he/she shall consider my personal values as much as possible and make decisions that he/she thinks are in my best interest. I ask that when my agent is trying to consider my values and prior wishes, that he/she talk to other loved ones who know me and care about me. (initial here)

The following individual(s) are to be EXCLUDED from any part of health care decision-making for me:

No Exclusions (initial here)

AFTER MY DEATH

My agent will be able to authorize an autopsy, donate all or part of my body, and/or determine the disposition of my remains. If I have written a will or made funeral arrangements, my agent should follow those instructions on what happens to my body after my death or other arrangements I have made. If I want to make exceptions to this authority, I write them here or in an attachment to this form:

No Exceptions (initial here)

(Sign and date the attached pages when this document is witnessed.)

PART 2: HEALTH CARE INSTRUCTIONS (Cross out the sections that do not apply)

I have made additional written instructions to my agent and attached them. (initial here)

(Sign and date the attached pages when this document is witnessed.)

TRUST IN AGENT: The instructions I give to my agent are guidelines to assist him/her in making the best medical decisions for me. The subject of unacceptable treatments is a complex one. Whether I would or would not want a particular medical intervention might depend on context. At some point there might be a conflict between treatment instructions I have given and what my agent thinks best in circumstances that I could not have predicted. I trust that my agent will honor my goals and values. (initial here)

PERSONAL CARE DECISIONS: By my initials here I direct that my agent(s) named above authorize personal care on my behalf including, but not limited to, choice of residence, clothing, receipt of my mail, care for my personal belongings, care for my pet(s) if any, and all other decisions of a personal nature not included in the description of health care. (initial here)

DNR ORDER: I have completed a Prehospital Do Not Resuscitate Form. (initial here)

REVOCATION OF PREVIOUS DOCUMENTS: I revoke any previously-executed Power of Attorney for Health Care, Individual Health Care Instruction, or Natural Death Act Declaration. I have the right to revoke this directive at a future date by creating a new one.

PART 3: SIGNATURE OF PERSON WHO IS MAKING THIS DIRECTIVE

Sign the document in the presence of the witnesses or the Notary.

Date:

Signature:

If the person making this directive is unable to write, have the person make a mark, have a witness write the name of the person making this directive and sign next page.

PART 4: THIS DOCUMENT MUST EITHER BE NOTARIZED OR SIGNED BY TWO WITNESSES ON THE NEXT PAGE.

WITNESSES:

Certain individuals cannot serve as witnesses. Those rules are set forth in the following witness statements:

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 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.

First Witness:

Date:

Address:

Signature:

Second Witness:

Signature:

Date:

Address:

ONE OF THE PRECEDING WITNESSES ALSO MUST SIGN THE FOLLOWING DECLARATION:

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 operations of law.

Date:

Signature:

Only if the person making this directive is unable to write, witnesses complete this section:

, being unable to write, made his/her mark in our presence and requested the first of the undersigned to write his/her name, which he/she did, and we now subscribe our names as witnesses thereto.

Signature of Witness #1

Signature of Witness #2

If the principal (the person appointing the agent) currently resides in a nursing facility, this document also must be witnessed by a representative of California’s Long-Term Care Ombudsman Program. If the two-witness method is chosen, the Ombudsman Program representative may serve as one of the two witnesses, or may serve as a third witness. If the notarization method is chosen, the Ombudsman Program representative serves as a separate witness.

DECLARATION OF OMBUDSMAN PROGRAM REPRESENTATIVE

(Required ONLY if person appointing the agent currently resides in a nursing facility.) I declare under penalty of perjury under the laws of California that I am an ombudsman designated by the California Department of Aging and that I am serving as a witness as required by Section 4675 of the California Probate Code.

Name (printed)

Signature

Date

CERTIFICATE OF ACKNOWLEDGEMENT OF NOTARY PUBLIC

(Not required if two-witness method is followed)

State of California, County of

On this day of , , before me, the undersigned, a Notary Public in and for said State, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument, and acknowledged to me that he/she executed it.

WITNESS my hand and official seal.

(seal)

Signature

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What the Kaiser Health Care Directives Form Is

The Kaiser Health Care Directives Form documents a patient's instructions about medical treatment choices and appoints a health care agent for decision-making if the patient becomes incapacitated. It typically includes a living will section for specific treatment preferences and a durable power of attorney for health care naming an agent. The form is used to ensure clinicians and medical records reflect the patient’s wishes across care settings within the Kaiser Permanente system and can be added to the electronic health record for reference by treating providers.

Why the Form Matters for Patient Care

Completing a Kaiser Health Care Directives Form ensures your treatment preferences are known and an authorized decision-maker is identified, reducing uncertainty during serious illness.

Why the Form Matters for Patient Care

Who Typically Completes This Form

Patients, caregivers, and clinicians use the form to record preferences and name a health care agent before a crisis.

  • Patients with chronic or serious illnesses who want to document future treatment preferences.
  • Adults who wish to designate a surrogate decision-maker for health care choices.
  • Caregivers and family members coordinating care transitions or hospital admissions.

Use it to align medical treatment with patient values and to provide clear instructions for admissions, surgeries, and chronic care planning.

Step-by-Step: Completing the Kaiser Health Care Directives Form

Follow these ordered steps to complete the form and ensure it becomes part of the medical record.

  • 01
    Gather IDs: Have government ID and patient info ready.
  • 02
    Name Agent: Enter primary and alternate agent contact details.
  • 03
    State Preferences: Specify desired treatments and limits clearly.
  • 04
    Sign and Witness: Sign, date, and obtain witnesses or notarization as required.

Core Sections of a Complete Directive

A professional Kaiser Health Care Directives Form includes distinct sections to capture identity, decision authority, and treatment preferences clearly and legally.

Patient Identification

Full name, DOB, medical record number, and contact information to ensure the document is matched correctly in the electronic health record.

Health Care Agent

Designation of a primary surrogate with full contact details and authority scope, plus alternates to avoid gaps in decision-making.

Living Will

Clear statements about life-sustaining treatment, resuscitation, tube feeding, and other interventions to guide clinicians.

Limitations and Conditions

Optional detailed scenarios or conditions under which specific treatments should or should not be used, improving clarity for providers.

Witness / Notary

A witness and/or notary section to meet state formalities; some states require two witnesses or notarization for enforceability.

Provider Acknowledgment

Space for healthcare provider or facility staff to record receipt and inclusion in the medical record for continuity of care.

Required Data Elements at a Glance

Patient Name: Exact legal name
Date of Birth: MM/DD/YYYY
Agent Contact: Phone and address
Treatment Choices: Clear directives
Signatures: Patient and witnesses
Date Signed: MM/DD/YYYY

Supporting Documents to Include

Attach or provide related records to reduce ambiguity and speed processing when adding the directive to a medical file.

Photo ID

A copy of government-issued identification helps verify the patient’s identity when matching forms to the health record.

Previous Directives

Include any older advance directives or revocation documents so staff can reconcile and record the most recent instruction.

Physician Notes

Relevant clinical notes or diagnoses can clarify the context for the stated treatment preferences.

Power of Attorney

If a separate durable power of attorney for finances exists, include it to document roles across legal matters.

How to Complete and Submit Digitally

Configure the digital workflow to collect signatures, verify identity, and deliver the signed directive into the Kaiser medical record.

Field Configuration
Signature Field Require signature and date
Witness Fields Conditional display per state rules
Authentication Email plus optional SMS code
Delivery Export PDF to EHR upload

Digital Signing and Submission Considerations

Ensure the signing platform supports secure authentication and preserves an audit trail for legal validity.

  • Document Formats: PDF and DOCX supported
  • Authentication: Email, SMS, or KBA
  • Recordkeeping: Audit trail and tamper-evident seal

Verify the platform meets HIPAA, ESIGN/UETA requirements and that the signed copy is stored with the patient’s medical record.

Distribution: How the Signed Form Moves Between Parties

Typical distribution routes ensure the directive is available to clinicians, agents, and the medical record after signing.

  • Patient to Agent: Provide signed copy to your health care agent immediately.
  • Upload to EHR: Clinic staff or patient uploads the PDF to electronic health record.
  • Clinic Reception: Front desk files copy in patient chart for admissions.
  • Emergency Access: Stored directive accessible to treating providers during urgent care.

Timing: When to Complete and Share the Form

Complete or update the directive whenever health status, preferences, or agents change; share it before admissions or major procedures.

Before Admission:

Provide the form to the admitting facility at or before hospital admission.

Post-Diagnosis:

Complete within weeks of a new serious diagnosis to document preferences.

After Major Change:

Update the form immediately after significant changes in health or relationships.

Periodic Review:

Review annually or when medications or prognosis change.

Upon Revocation:

Deliver revocation notice to provider and agent immediately.

Common Mistakes to Avoid

  • Using vague language that leaves treatment decisions open to interpretation by clinicians or courts.
  • Failing to name an alternate agent, creating a gap if the primary agent is unavailable or incapacitated.
  • Neglecting to follow your state’s witness or notarization requirements, which can invalidate the document.
  • Not providing signed copies to providers and the named agent, limiting the form’s practical effect.

Potential Consequences of an Incorrect or Incomplete Directive

Invalidation Risk: Mismatched signatures may make the directive unenforceable
Treatment Delay: Unclear instructions can delay clinically appropriate care
Legal Challenge: Family disputes may lead to court intervention
HIPAA Breach: Improper sharing risks violations
Administrative Rejection: Missing witness/notary can cause refusal
Outdated Instructions: Older versions may not reflect current wishes

eSignature Pricing Snapshot for Health Care Directives

Compare typical entry-level pricing and core features useful for healthcare directives; signNow is listed first per vendor comparison guidance.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently Asked Questions About the Kaiser Health Care Directives Form

Answers below address common execution, legal validity, and submission issues when completing a directive for Kaiser care.


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