GC-380 Petition for Exclusive Authority to Give Consent for Medical Treatment

Source: https://www.courts.ca.gov/documents/gc380.pdf

GC-380 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.: E-MAIL ADDRESS: ATTORNEY FOR (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CONSERVATORSHIP OF THE PERSON ESTATE OF (Name):

CONSERVATEE
PETITION FOR EXCLUSIVE AUTHORITY TO GIVE CASE NUMBER:
CONSENT FOR MEDICAL TREATMENT

1. Petitioner (name): requests that a. the conservatee be adjudged to lack the capacity to give informed consent to medical treatment or healing by prayer. b. the conservator of the person be granted the exclusive authority to give consent to medical treatment or healing by prayer that the conservator in good faith based on medical advice determines to be necessary. c. the treatment be performed by a licensed medical practitioner a licensed psychologist within the scope of his or her license an accredited practitioner of a religion that relies on prayer alone for healing. d. orders related to the care and treatment of a major neurocognitive disorder (such as dementia) as specified in the Attachment Requesting Special Orders Regarding a Major Neurocognitive Disorder be granted. (Attach form GC-313.) e. the order dated (specify): made under Probate Code section 1880 be revoked be modified as specified in Attachment 1e be modified as follows (specify):

   f. other orders be granted as specified in Attachment 1f as follows (specify):

   g. Letters of Conservatorship be reissued to include a statement that conservator has the powers requested in this petition.

2. There is no form of medical treatment for which the proposed conservatee has the capacity to give informed consent.

3. Attached to this petition is a declaration executed by a licensed physician stating that the conservatee lacks the capacity to give informed consent for any form of medical treatment and giving reasons and the factual basis for this conclusion. (Label as Attachment 3.)

4. Conservatee is is not an adherent of a religion that relies on prayer alone for healing as defined in Probate Code section 2355(b).

Form Adopted for Mandatory Judicial Council of California Use PETITION FOR EXCLUSIVE AUTHORITY TO GIVE Probate Code,www.courts.ca.gov§ 1880 et seq. GC-380 [Rev. January 1, 2019] CONSENT FOR MEDICAL TREATMENT (Probate Conservatorship)

GC-380 CONSERVATORSHIP OF (Name): CASE NUMBER:

CONSERVATEE

5. ATTENDANCE AT THE HEARING Conservatee a. will attend the hearing. b. is able but unwilling to attend the hearing AND does does not wish to contest this petition. c. is unable to attend the hearing because of medical inability. An affidavit or certificate of a licensed medical practitioner or an accredited religious practitioner is affixed as Attachment 5c. d. is not the petitioner, is out of state, and will not attend the hearing.

6. Special notice has has not been requested. (Specify the names and addresses of persons requesting special notice in Attachment 6.)

7. Filed with this petition is a proposed Order Appointing Court Investigator (form GC-330) that specifies the duties to be performed before granting an order relating to medical consent .

8. The names, residence addresses, and relationships of the spouse and all relatives within the second degree of the conservatee so far as known to petitioner are listed below listed in Attachment 8.

   Relationship and name Residence address

   a. Spouse:

   b.

9. Number of pages attached:

Date: (Signature of all petitioners also required (Prob. Code, § 1020).) (SIGNATURE OF ATTORNEY) 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 NAME ) (SIGNATURE OF PETITIONER)

Date:

(TYPE OR PRINT NAME ) (SIGNATURE OF PETITIONER)

GC-380 [Rev. January 1, 2019] PETITION FOR EXCLUSIVE AUTHORITY TO GIVE Page 2 of 2 CONSENT FOR MEDICAL TREATMENT (Probate Conservatorship) For your protection and privacy, please press the Clear This Form button after you have printed the form. Print this form Save this form Clear this form