GC-333 Ex Parte Application for Order Authorizing Completion of Capacity Declaration—HIPAA

Source: https://www.courts.ca.gov/documents/gc333.pdf

GC-333 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO.: EMAIL ADDRESS: ATTORNEY FOR (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CASE NUMBER: CONSERVATORSHIP OF THE PERSON ESTATE OF

(name): CONSERVATORSHIP PETITION HEARING DATE: PROPOSED CONSERVATEE EX PARTE APPLICATION FOR ORDER AUTHORIZING TIME: DEPT.: COMPLETION OF CAPACITY DECLARATION—HIPAA*

1. Applicant (name): has filed a petition for the appointment of a conservator for the above-named proposed conservatee. The petition is set for hearing on (date): at (time): in Dept.: Rm.:

2. The petition requests (check all that apply): a. A finding that the proposed conservatee should be excused from attending the hearing on the petition. b. Exclusive authority to consent to medical treatment for the proposed conservatee. c. Authority to make placement or medication decisions related to a major neurocognitive disorder (such as dementia). d. Appointment of a conservator of the estate. e. Other (specify):

3. Applicant has requested (name each declarant):

   to complete, sign, and deliver to applicant, for use to support the petition, a Confidential Capacity Assessment and Declaration—Probate Conservatorship (form GC-335) and an Everyday Activities Attachment to Confidential Capacity Assessment and Declaration—Probate Conservatorship (form GC-335A) (the Declaration) concerning the medical condition or mental capacity of (name of proposed conservatee):

4. The proposed conservatee has not consented to the disclosure of any private medical information that would be disclosed by the completed Declaration.

5. Applicant requests this court to authorize each declarant named in item 3 to complete, sign, and deliver the Declaration to applicant within 15 days of the declarant's receipt of the court's order.

6. Applicant requests this court to dispense with notice of hearing on this application.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date:

(TYPE OR PRINT APPLICANT'S NAME) (APPLICANT'S SIGNATURE )

• The federal Health Insurance Portability and Accountability Act of 1996. Use this form with Ex Parte Order re Completion of Capacity Declaration— HIPAA (form GC-334).

Judicial Council of California, courts.ca.gov GC-333, Page 1 of 1Rev. January 1, 2026, Mandatory Form Ex Parte Application for Order Authorizing Prob. Code, §§ 1801, 1872, 1890, 2356.5; Civ. Code, §§ 56.10, 56.13; 45 C.F.R. §§ 160, 164 Completion of Capacity Declaration—HIPAA For your protection and privacy, please press the Clear button after you have printed the form. Print Save Clear