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Here is the text we could read:

ATTORNEY OR PARTY WITHOUT ATTORNEY

STATE BAR NUMBER:

FOR COURT USE ONLY

GC-334

STATE:

FAX NO.:

ZIP CODE:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:

NAME:

FIRM NAME:

STREET ADDRESS:

CITY:

TELEPHONE NO.:

E-MAIL ADDRESS:

ATTORNEY FOR (name):

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

(Name):

CONSERVATORSHIP OF THE OF

PERSON

ESTATE

CASE NUMBER:

PROPOSED CONSERVATEE

CONSERVATORSHIP PETITION HEARING DATE:

DEPT.:

TIME:

EX PARTE ORDER RE COMPLETION OF CAPACITY DECLARATION—HIPAA*

1. Attached to this order is a Capacity Declaration—Conservatorship (form GC-335)

and a Major Neurocognitive Disorder Attachment to Capacity Declaration—Conservatorship (form GC-335A) (the
Declaration).

(Name):
having applied for an order authorizing the declarant(s) named in item 5 to complete, sign, and return the Declaration for the
purpose specified in item 6, and good cause appearing:

THE COURT FINDS
3. Notice of the hearing on the application should be dispensed with and the application should be granted.

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):

Dept.

:Rm.

5. Declarant (name each):

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):

A finding that the proposed conservatee should be excused from attending the hearing on the petition.

A request for exclusive authority to consent to medical treatment for the proposed conservatee.

A request for authority to make placement and medication decisions related to treatment of a major neurocognitive
disorder (including dementia).

The appointment of a conservator of the estate.

Other (specify):

* The federal Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191).

Form Adopted for Mandatory Use
Judicial Council of California
GC-334 [Rev. January 1, 2019]

EX PARTE ORDER RE COMPLETION OF
CAPACITY DECLARATION—HIPAA
(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. §§ 160, 164
www.courts.ca.gov

CONSERVATORSHIP OF (Name):

CASE NUMBER:

GC-334

THE COURT ORDERS

7. Notice of hearing on the application is dispensed with.

PROPOSED CONSERVATEE

8. 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):

and Major Neurocognitive Disorder Attachment to Capacity Declaration—Conservatorship (form GC-335A)
(name each 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.

Use of the Declaration is governed by the disclosure safeguards in the regulations of the federal Department of Health and Human
Services (45 C.F.R. §§ 160 & 164) under HIPAA, 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):

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

CERTIFICATION

JUDICIAL OFFICER

Clerk, by

, Deputy

Date:

(SEAL)

GC-334 [Rev. January 1, 2019]

Page 2 of 2

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

Ex Parte Order Re Completion of Capacity Declaration—HIPAA

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 2
Fields(s): 48
Average fields per page: 24
Reading Level: Grade 10
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

g_c_page_fill_text__1 was GC-334[0].Page1[0].FillText1[0] (0.58 conf)
c_page_std_p_info_county was GC-334[0].Page1[0].StdP1Header[0].CourtInfo[0].CrtCounty[0] (0.39 conf)
g_c_page_std_p_header_court_info_crt_branch was GC-334[0].Page1[0].StdP1Header[0].CourtInfo[0].CrtBranch[0] (0.39 conf)
c_page_std_p_header_city was GC-334[0].Page1[0].StdP1Header[0].CourtInfo[0].CrtCityZip[0] (0.37 conf)
c_page_std_p_header_street was GC-334[0].Page1[0].StdP1Header[0].CourtInfo[0].CrtStreet[0] (0.39 conf)
page_header_court_info_crt_mailing was GC-334[0].Page1[0].StdP1Header[0].CourtInfo[0].CrtMailingAdd[0] (0.35 conf)
c_page_std_p_title_name__1 was GC-334[0].Page1[0].StdP1Header[0].TitlePartyName[0].Party1[0] (0.39 conf)
c_page_std_p_title_name__2 was GC-334[0].Page1[0].StdP1Header[0].TitlePartyName[0].CBChoice1[0] (0.40 conf)
c_page_std_p_title_name__3 was GC-334[0].Page1[0].StdP1Header[0].TitlePartyName[0].CBChoice1[1] (0.40 conf)
c_page_std_p_stamp_number was GC-334[0].Page1[0].StdP1Header[0].Stamp[0].CaseNumber[0] (0.39 conf)
c_page_std_p_stamp_date was GC-334[0].Page1[0].StdP1Header[0].Stamp[0].PetHearingDate[0] (0.38 conf)
c_page_std_p_info_dept was GC-334[0].Page1[0].StdP1Header[0].HearingInfo[0].HearingDept[0] (0.40 conf)
c_page_std_p_info_time was GC-334[0].Page1[0].StdP1Header[0].HearingInfo[0].HearignTime[0] (0.39 conf)
c_page_std_p_party_info__1 was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].State[0] (0.40 conf)
c_page_std_p_header_info__1 was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].Zip[0] (0.40 conf)
c_page_std_p_party_city was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].City[0] (0.40 conf)
c_page_std_p_party_info__2 was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].Street[0] (0.40 conf)
c_page_std_p_party_info__3 was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].Firm[0] (0.40 conf)
c_page_std_p_info_name was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].Name[0] (0.40 conf)
c_page_std_p_party_info__4 was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].Phone[0] (0.40 conf)
c_page_std_p_header_info__2 was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].Fax[0] (0.40 conf)
c_page_std_p_info_email was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].Email[0] (0.40 conf)
c_page_std_p_party_info__5 was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].AttyFor[0] (0.38 conf)
c_page_std_p_party_info__6 was GC-334[0].Page1[0].StdP1Header[0].AttyPartyInfo[0].BarNo[0] (0.36 conf)
g_c_page_area_fill_text__1 was GC-334[0].Page1[0].#area[0].FillText1[1] (0.38 conf)
g_c_page_area_fill_text__2 was GC-334[0].Page1[0].#area[0].FillText1[2] (0.38 conf)
g_c_page_area_text_field__1 was GC-334[0].Page1[0].#area[0].#area[1].TextField2[0] (0.41 conf)
g_c_page_area_check_box__1 was GC-334[0].Page1[0].#area[0].#area[1].CheckBox61[0] (0.37 conf)
g_c_page_area_text_field__2 was GC-334[0].Page1[0].#area[0].#area[2].TextField2[1] (0.41 conf)
g_c_page_area_check_box__2 was GC-334[0].Page1[0].#area[0].#area[2].CheckBox61[1] (0.37 conf)
g_c_page_area_checkbox_cb__1 was GC-334[0].Page1[0].#area[3].checkbox_cb[0] (0.32 conf)
g_c_page_fill_text__2 was GC-334[0].Page1[0].FillText1[3] (0.38 conf)
g_c_page_fill_text__3 was GC-334[0].Page1[0].FillText1[4] (0.38 conf)
g_c_page_area_checkbox_cb__2 was GC-334[0].Page1[0].#area[4].checkbox_cb[1] (0.32 conf)
g_c_page_area_checkbox_cb__3 was GC-334[0].Page1[0].#area[5].checkbox_cb[2] (0.32 conf)
g_c_page_area_checkbox_cb__4 was GC-334[0].Page1[0].#area[6].checkbox_cb[3] (0.32 conf)
g_c_page_area_checkbox_cb__5 was GC-334[0].Page1[0].#area[7].checkbox_cb[4] (0.32 conf)
g_c_page_text_field__1 was GC-334[0].Page1[0].TextField6[0] (0.41 conf)
g_c_page_area_check_box__3 was GC-334[0].Page1[0].#area[8].CheckBox19[0] (0.37 conf)
g_c_page_fill_text__4 was GC-334[0].Page2[0].FillText1140[0] (0.38 conf)
g_c_page_px_case_number was GC-334[0].Page2[0].PxCaption[0].CaseNumber[0].CaseNumber[0] (0.38 conf)
c_page_caption_title_party_name was GC-334[0].Page2[0].PxCaption[0].TitlePartyName[0].Party1[0] (0.36 conf)
g_c_page_fill_text__5 was GC-334[0].Page2[0].FillText1[0] (0.38 conf)
g_c_page_area_checkbox_cb__6 was GC-334[0].Page2[0].#area[0].checkbox_cb[0] (0.32 conf)
g_c_page_text_field__2 was GC-334[0].Page2[0].TextField6[0] (0.41 conf)
g_c_page_fill_text__6 was GC-334[0].Page2[0].FillText1[1] (0.38 conf)
g_c_page_fill_text__7 was GC-334[0].Page2[0].FillText1140[1] (0.38 conf)
g_c_page_text_field__3 was GC-334[0].Page2[0].TextField6[1] (0.41 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Ex Parte Order Re Completion of Capacity Declaration—HIPAA

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02