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Here is the text we could read:

ATTORNEY OR PARTY WITHOUT ATTORNEY

STATE BAR NUMBER:

GC-333

FOR COURT USE ONLY

NAME:

FIRM NAME:

STREET ADDRESS:

CITY:

TELEPHONE NO.:

E-MAIL ADDRESS:

ATTORNEY FOR (name):

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:

STATE:

FAX NO.:

ZIP CODE:

CONSERVATORSHIP OF THE
(Name):

PERSON

ESTATE OF

CASE NUMBER:

PROPOSED CONSERVATEE

CONSERVATORSHIP PETITION HEARING DATE:

EX PARTE APPLICATION FOR ORDER AUTHORIZING
COMPLETION OF CAPACITY DECLARATION—HIPAA*

DEPT.:

TIME:

1. Applicant (name):

has filed a petition for the appointment of a conservator for the above-named proposed conservatee. The petition is set for
hearing on (date):

at (time):

Dept.:

Rm.:

2. The petition requests (check all that apply):

a.
b.
c.
d.
e.

A finding that the proposed conservatee should be excused from attending the hearing on the petition.
Exclusive authority to consent to medical treatment for the proposed conservatee.
Authority to make placement or medication decisions related to a major neurocognitive disorder (such as dementia).
Appointment of a conservator of the estate.
Other

(specify):

3. Applicant has requested (name each declarant):

to complete, sign, and deliver to applicant, for use to support the petition, a

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

(the Declaration), concerning the medical condition or mental capacity of (name of proposed conservatee):

The proposed conservatee has not consented to the disclosure of any private medical information that would be disclosed by the
completed Declaration.

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:

(TYPE OR PRINT APPLICANT'S NAME)

(APPLICANT'S SIGNATURE )

* The federal Health Insurance Portability and Accountability Act of 1996. Use this form with Ex Parte Order Re Completion of Capacity

Declaration—HIPAA (form GC-334).

Form Adopted for Mandatory Use
Judicial Council of California
GC-333 [Rev. January 1, 2019]

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

Ex Parte Application for Order Authorizing 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): 1
Fields(s): 42
Average fields per page: 42
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_check_box__1 was GC-333[0].Page1[0].CheckBox1[0] (0.56 conf)
g_c_page_check_box__2 was GC-333[0].Page1[0].CheckBox1[1] (0.37 conf)
g_c_page_check_box__3 was GC-333[0].Page1[0].CheckBox1[2] (0.37 conf)
g_c_page_check_box__4 was GC-333[0].Page1[0].CheckBox1[3] (0.37 conf)
g_c_page_check_box__5 was GC-333[0].Page1[0].CheckBox1[4] (0.37 conf)
c_page_p_court_info_county was GC-333[0].Page1[0].P1Caption[0].CourtInfo[0].CrtCounty[0] (0.36 conf)
c_page_p_caption_court_info was GC-333[0].Page1[0].P1Caption[0].CourtInfo[0].CrtBranch[0] (0.36 conf)
g_c_page_p_caption_court_info_crt_city_zip was GC-333[0].Page1[0].P1Caption[0].CourtInfo[0].CrtCityZip[0] (0.35 conf)
c_page_p_caption_info_street was GC-333[0].Page1[0].P1Caption[0].CourtInfo[0].CrtStreet[0] (0.36 conf)
page_p_caption_court_info_mailing was GC-333[0].Page1[0].P1Caption[0].CourtInfo[0].CrtMailingAdd[0] (0.41 conf)
c_page_p_title_party_name was GC-333[0].Page1[0].P1Caption[0].TitlePartyName[0].Party1[0] (0.38 conf)
c_page_p_stamp_case_number was GC-333[0].Page1[0].P1Caption[0].Stamp[0].CaseNumber[0] (0.40 conf)
c_page_p_stamp_hear_date was GC-333[0].Page1[0].P1Caption[0].Stamp[0].HearDate[0] (0.40 conf)
c_page_p_hearing_info_dept was GC-333[0].Page1[0].P1Caption[0].HearingInfo[0].HearingDept[0] (0.40 conf)
c_page_p_hearing_info_time was GC-333[0].Page1[0].P1Caption[0].HearingInfo[0].HearingTime[0] (0.40 conf)
c_page_p_party_info_state was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].State[0] (0.39 conf)
g_c_page_p_party_info__1 was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].Zip[0] (0.39 conf)
c_page_p_party_info_city was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].City[0] (0.39 conf)
c_page_p_party_info_street was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].Street[0] (0.39 conf)
c_page_p_party_info_firm was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].Firm[0] (0.39 conf)
c_page_p_party_info_name was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].Name[0] (0.39 conf)
c_page_p_party_info_phone was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].Phone[0] (0.39 conf)
c_page_p_caption_party_info was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].Fax[0] (0.39 conf)
c_page_p_party_info_email was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].Email[0] (0.39 conf)
g_c_page_p_party_info__2 was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].AttyFor[0] (0.40 conf)
c_page_p_party_info_bar was GC-333[0].Page1[0].P1Caption[0].AttyPartyInfo[0].BarNo[0] (0.38 conf)
g_c_page_fill_text__1 was GC-333[0].Page1[0].FillText1140[0] (0.38 conf)
g_c_page_fill_text__2 was GC-333[0].Page1[0].FillText56[0] (0.38 conf)
g_c_page_check_box__6 was GC-333[0].Page1[0].CheckBox1[5] (0.37 conf)
g_c_page_check_box__7 was GC-333[0].Page1[0].CheckBox1[6] (0.37 conf)
g_c_page__1 was GC-333[0].Page1[0].T124[0] (0.33 conf)
g_c_page__2 was GC-333[0].Page1[0].T128[0] (0.33 conf)
g_c_page__3 was GC-333[0].Page1[0].T130[0] (0.33 conf)
g_c_page__4 was GC-333[0].Page1[0].T185[0] (0.33 conf)
g_c_page_specify was GC-333[0].Page1[0].OtherSpecify[0] (0.35 conf)
g_c_page_check_box__8 was GC-333[0].Page1[0].CheckBox1[7] (0.37 conf)
g_c_page_check_box__9 was GC-333[0].Page1[0].CheckBox1[8] (0.37 conf)
g_c_page_name_ft was GC-333[0].Page1[0].name_ft[0] (0.32 conf)
g_c_page_area_text_field__1 was GC-333[0].Page1[0].#area[0].TextField2[0] (0.41 conf)
g_c_page_area_check_box__1 was GC-333[0].Page1[0].#area[0].CheckBox61[0] (0.37 conf)
g_c_page_area_text_field__2 was GC-333[0].Page1[0].#area[1].TextField2[1] (0.41 conf)
g_c_page_area_check_box__2 was GC-333[0].Page1[0].#area[1].CheckBox61[1] (0.37 conf)

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

Ex Parte Application for Order Authorizing 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