LASC MH 021 Rev 11/18 For Mandatory Use ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar#, and Address) TELEPHONE NO: ATTORNEY FOR (Name): Reserved for Clerk222s File Stamp SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: IN THE MATTER OF THE APPLICATION OF: DOB: FOR APPEAL OF CAPACITY DECISION PATIENT APPEAL 226 MEDICATION CAPACITY WIC 247 5334(e)(1) CASE NUMBER : ZW TO: LOS ANGELES SUPERIOR COURT, COURTHOUSE- DEPARTMENT Your appellant respectfully alleges as follows; That I am, and a Medication Capacity Hearing was held at . The decision of the Hearing Officer declared that I lack the capacity to give an informed refusal and may be medicated against my will, is erroneous. There is no clear and convincing evidence that I lack the capacity to give an informed refusal and therefore should not be medicated against my will. WHEREFORE, your appellant respectfully prays that this court issue an order to: commanding that I be brought before this court at a specific time and place and that my treating physician be present and demonstrate by clear and convincing evidence that I lack capacity to give an informed refusal to medications. DATE (ATTORNEY FOR APPELLANT) The Clerk is directed to issue an Order calendaring the matter for hearing and requiring the presence of the patient and treating physician at the time and place specified in the Order. DATE Judge of the Superior Court ORDER FOR HEARING Toand (TREATMENT FACILITY) (TREATING PHYSICIAN) YOU ARE ORDERED to appear at DEPARTMENT of the Superior Court before Honorable Judge of the Superior Court, County of Los Angeles, State of California, on the day of , 20at 8:30 a.m. You are further ordered to have , a patient in custody together with all treatment records relating to said patient222s treatment. Given under my hand with the Seal of Said Court, this day of , 20. SHERRI R. CARTER, Executive Officer/Clerk of Court By: Deputy CERTIFICATE OF SERVICE I hereby certify that I received and served the above Appeal on the day of 20, and that I served the same by delivering said Appeal to on. (Person) (UNIT/WARD) (SIGNATURE) (PRINT NAME) (TITLE AND TELEPHONE NUMBER) American LegalNet, Inc. www.FormsWorkFlow.com