COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : :
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
FOR COURT USE ONLY
Plaintiff(s) -againstTELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional):
: : : :
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
Defendant(s) : MAILING ADDRESS: ......................................................
CITY AND ZIP CODE: BRANCH NAME:
CONSERVATORSHIP OF THE (Name): THE
PEOPLE OF THE STATE OF NEW YORK
CONSERVATORSHIP PETITION HEARING DATE:
EX PARTE APPLICATION FOR ORDER AUTHORIZING COMPLETION OF CAPACITY DECLARATION--HIPAA *
(Health Insurance Portability and Accountability Act of 1996)
1. Applicant (name): GREETINGS: has filed a petition for the appointment of a conservator for the above-named proposed conservatee. The petition is set for hearing on (date): COMMAND YOU, that all business and excuses being laid aside, you and each of you attend at (time): in Dept.: Rm.: WE
before , the Honorable (check all that apply): at the Court 2. The petition requests located atshould be excused from attending the hearing on the petition. CountyAof a. finding that the proposed conservatee , on the day of , for o'clock in noon, and at any recessed b. in room Exclusive authority to consent to medical treatment20 the , at proposed conservatee. the c. or adjourned date, to testify and give evidence as a witness in this action on the part of the Dementia powers.
d. e. Appointment of a conservator of the estate. Other (specify):
3. Applicant has Your failure to comply with this requested (name each declarant):
subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. , one of the Justices of the
to complete, sign, and deliver to applicant for use to support the petition, a Capacity Declaration--Conservatorship Dementia Attachment to Capacity Declaration--Conservatorship (form GC-335A ) (form GC-335) (the Declaration), concerning the medical condition or mental capacity of (name of proposed conservatee):
Witness, Honorable Court in County,
4. The proposed conservatee has not consented to the disclosure of any private medical information that would be disclosed by the completed Declaration. (Attorney must sign above and type name below) 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:
Office and P.O. Address
(TYPE OR PRINT APPLICANT'S NAME) (APPLICANT'S SIGNATURE )
For use with Ex Parte Order Re Completion of Capacity Declaration--HIPAA (form GC-334).
Form Adopted for Mandatory Use Judicial Council of California GC-333 [New July 1, 2005]
Telephone No.: Facsimile No.: EX PARTE APPLICATION FOR ORDER AUTHORIZING E-Mail Address: COMPLETION OF CAPACITY DECLARATION--HIPAA Mobile Tel. No.:
(Probate--Guardianships and Conservatorships)
Page 1 of 1 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
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