Free GC-334 EX PARTE ORDER RE COMPLETION OF CAPACITY DECLARATION--HIPAA (PROBATE--GUARDIANSHIPS AND CONSERVATORSHIPS) - California

COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : :
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

Index No. Calendar No.
FOR COURT USE ONLY

GC-334

Plaintiff(s) -againstTELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional):

: : : :

JUDICIAL SUBPOENA

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS:

Defendant(s) : ......................................................
CITY AND ZIP CODE: BRANCH NAME: CASE NUMBER:

CONSERVATORSHIP OF THE

PERSON

ESTATE

OF

THE (Name): TO

PEOPLE OF THE STATE OF NEW YORK
CONSERVATORSHIP PETITION HEARING DATE:

PROPOSED CONSERVATEE
DEPT.: TIME:

EX PARTE ORDER RE COMPLETION OF CAPACITY DECLARATION--HIPAA
(Health Insurance Portability and Accountability Act of 1996)

1. Attached to this order is a Capacity Declaration--Conservatorship (form GC-335) GREETINGS: and a Dementia Attachment to Capacity Declaration--Conservatorship (form GC-335A ) (the Declaration). 2. (Name):

WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before ,

has applied for an order authorizing the declarant named in item 5 to complete, sign, and return the Declaration for the purpose the Honorable at the Court specified in of 6 and good cause appearing, item located at County THE COURT FINDS in room

, on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the partgranted. of the 3. Notice of the hearing on the application should be dispensed with and the application should be

4. A petition for the appointment of a conservator has been filed in this proceeding by (name of petitioner):

this subpoena is at (time): punishable as a contempt of court and will make you liable to in Rm.: Dept.: the party on each): behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a whose 5. Declarant (name result of your failure to comply. Witness, Honorable , 6. has been requested to complete and sign the Declaration for the purpose specified in item one Court in County, day of , 20 of the Justices of the

This petition is set for hearing on (date): with Your failure to comply

6. Petitioner proposes to use the Declaration to provide evidence to support (check all that apply): A finding that the proposed conservatee should be excused from attending the hearing on the petition. a. A request for exclusive authority to consent to medical treatment for the proposed conservatee. b. A request for dementia powers. c. (Attorney must sign above and type name below) The appointment of a conservator of the estate. d. e. Other (specify):

Attorney(s) for

Office and P.O. Address

Form Adopted for Mandatory Use Judicial Council of California GC-334 [New July 1, 2005]

(Probate--Guardianships and Conservatorships)

Telephone No.: Facsimile No.: E-Mail Address: EX PARTE ORDER RE COMPLETION OF CAPACITY DECLARATION--HIPAA No.: Mobile Tel.

Page 1 of 2 Probate Code, §§ 1220, 1825, 1890, 1893, 2356.5; 42 U.S.C. §§ 1177, 1178; 45 C.F.R. parts 160 and 164 www.courtinfo.ca.gov

American LegalNet, Inc. www.USCourtForms.com

CONSERVATORSHIP OF (Name):

CASE NUMBER:

PROPOSED CONSERVATEE

THE COURT ORDERS 7. 8. Notice is dispensed with. Each declarant named below is authorized to complete, sign, and deliver to the attorney or other person whose address appears at the top of page 1 of this order the original of the Declaration, consisting of: a. Capacity Declaration--Conservatorship (form GC-335) (name each authorized declarant):

b.

and Dementia Attachment to Capacity Declaration--Conservatorship (form GC-335A) (name authorized declarant): ,

regarding (name of proposed conservatee): to enable the Court to determine whether the proposed conservatee should be excused from attending the hearing on the appointment of a conservator or the proposed conservator should be granted certain powers over the person or estate of the proposed conservatee. 9. Use of the Declaration is governed by the disclosure safeguards contained in the regulations of the federal Department of Health and Human Services (45 C.F.R. parts 160 and 164) under the Health Insurance Portability and Accountability Act of 1996 (Public Law No. 104-191 (August 21, 1996)), and no use other than what is permitted in those regulations is permitted by this order.

10. The completed and signed original of the Declaration must be returned to the attorney or other person whose address appears at the top of this order within 15 days after its receipt by the declarant authorized to complete and sign it. 11. Other orders (specify):

Date: Judicial Officer

CERTIFICATION
I certify that this document and any attachments is a correct copy of the original on file in my office.

Date: Clerk, by
(SEAL)

, Deputy

GC-334 [New July 1, 2005]

EX PARTE ORDER RE COMPLETION OF CAPACITY DECLARATION--HIPAA
(Probate--Guardianships and Conservatorships)

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