Advance Health Care Directive

You can download and print this 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.

How to Share your Advance Health Care Directive with KP

Keep the original.

• Email your completed Advance Health Care Directive to SCALCentralized-Scanning-Center@kp.org

OR

• Mail your completed Advance Health Care Directive to:

Central Scanning

1011 S East St

Anaheim, CA 92805

Introduction (page 1)

1-A

Learn more about our approach to Life Care Planning

1-B

Please remember to write these items on every page:

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

Part 1: My Health Care Agent (page 2)

2-A

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

2-B

Learn more about what is an agent and their responsibilities.

2-C

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

Part 1: My Health Care Agent (page 3)

3-A

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

3-B

Video: What I might consider when choosing my agent.

Part 1: My Health Care Agent (page 4)

4-A

This 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-B

Learn more about these situations.

Part 2: My Values (page 5)

5-A

In 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-B

For further guidance, read your values are at the center of your life care plan.

5-C

Consider some situations where values matter.

5-D

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

Part 3: My Health Care Instructions (page 6)

6-A

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

6-B

Video: Get more details about this brain injury scenario.

6-C

Video: Learn more about accepting life sustaining treatments for a specific time period, in this scenario.

Part 3: My Health Care Instructions (page 7)

7-A

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

Part 4: My Hopes and Wishes (page 8)

8-A

Sometimes, 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-B

If 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.

Part 4: Organ Donation, other wishes (page 9)

9-A

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

Part 5: Making this document legally valid (page 10)

10-A

Learn more about making this document legally valid.

10-B

Please note that a witness may not be your appointed health care agent. In addition, remember:

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

10-C

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

Part 5: Making this document legally valid (page 11)

11-A

Learn more about making this document legally valid.

11-B

Please note that a health care agent can’t also be a witness.

Part 5: Making this document legally valid (page 12)

12-A

If 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-B

A 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.

Part 6: Next steps (page 13)

13-A

Learn more about sharing your values with your agent.

13-B

If 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-C

Read more: Who needs to know about your Life Care Plan?