FOR COURT USE ONLY ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, MADGE BRADLEY, 1409 4TH AVE., SAN DIEGO, CA 92101 Conservatorship of the Person Estate of Conservatee Proposed Conservatee CASE NUMBER: ORDER RE COMPLETION OF CAPACITY DECLARATION A petition having been filed for the appointment of a conservator of the person with medical powers, with dementia powers, estate, or a request for a finding that the proposed conservatee should be excused from attending the hearing has been made, Good Cause Appearing, IT IS ORDERED THAT: Dr. is hereby authorized to complete the attached Capacity Declaration – Conservatorship (Judicial Form #GC-335) regarding ________________ (proposed) Conservatee, in order to permit the Court to determine whether conservatorship powers over the person and/or estate of said person should be granted by the Court. The use of this declaration is governed by the disclosure safeguards incorporated in the HIPAA Privacy Regulations (45 CFR part 160 and part 164), and no use other than what is permitted in those regulations is permitted by this Court Order. The attached Capacity Declaration – Conservatorship must be returned to the attorney or person other than an attorney whose address appears at the top of this Order within fifteen days after its receipt by the individual or institution authorized to complete the Capacity Declaration. Date: Judge of the Superior Court SDSC PR-007 (Rev. 9/12) ORDER RE COMPLETION OF CAPACITY DECLARATION American LegalNet, Inc. www.FormsWorkFlow.com