Free GC-334 - California

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

GC-334

Index No.
FOR COURT USE ONLY

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

Calendar No. keep other people from To
seeing what you entered on your form, please press JUDICIAL SUBPOENA atthe Clear This Form button the end of the form when finished.

: : : :

-against-

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE:

Defendant(s) : .BRANCH.NAME: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ...
PERSON ESTATE OF
CASE NUMBER:

CONSERVATORSHIP OF THE (Name):

CONSERVATORSHIP PETITION HEARING DATE:

THE PEOPLE OF THE STATE OF NEW YORK TO

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) and a Dementia Attachment to Capacity Declaration--Conservatorship (form GC-335A ) (the Declaration).

GREETINGS: 2. (Name):
has applied for an order authorizing the declarant named in item 5 to complete, sign, and return the Declaration for the purpose WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before specified in item 6 and good cause appearing,

the Honorable

at the

Court

,

THE COURT FINDS County of

located at

, application shouldof dispensed with and the application should be granted. day be , 20 , at o'clock in the noon, and at any recessed of the hearing on the on the 3. Noticein room
4. A petition for the appointment of a conservator has been filed in this proceeding by (name of petitioner): This petition is set for hearing on (date): at (time): in Dept.:

or adjourned date, to testify and give evidence as a witness in this action on the part of the
Rm.:

5. Declarant (name Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to each):

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.
has been requested to complete and sign the Declaration for the purpose specified in item 6. 6. Petitioner proposes to use the Declaration to provide evidence to support (check all that apply): Court in County, day of , 20 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):

Witness, Honorable

, one of the Justices of the

Attorney(s) for

Office and P.O. Address

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

Telephone No.: Facsimile No.: EX PARTE ORDER RE COMPLETIONAddress: E-Mail OF CAPACITY DECLARATION--HIPAA Mobile Tel. No.: (Probate--Guardianships and Conservatorships)

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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