(1) "Health care provider" means an individual licensed, certified, or otherwise authorized or permitted by the law of California or of any other jurisdiction to provide health care in the ordinary course of business or practice of a profession.

(2) "The public guardian" means a public official of any jurisdiction who is serving in his or her official capacity as the guardian or conservator for the registrant.

(3) "The legal representative of the registrant" means an individual who is either:

(A) serving as the guardian or conservator for the registrant pursuant to an order of a court of any jurisdiction; or

(B) designated in a current written advance health care directive or similar written document registered with the Secretary of State to make health care decisions for the registrant.

(1) "Other authorized persons" means the legal representatives of registrants as defined in Section 22610.1(a)(3) of Article 1, Chapter 14, Division 7, Title 2, California Code of Regulations.

(1) The name and number of the form;

(2) The name and seal of the agency promulgating the form;

(3) Space for the Secretary of State’s Office to record filing information and file number;

(4) The statutory and regulatory citations for the program to which the form relates;

(5) The fee for filing the form and any amendments or revocations involving the form or the written advance health care directive to which the form relates;

(6) Instructions regarding the completion, amendment, revocation or filing of the form or registering, revoking or changing a written advance health care directive to which the form relates;

(7) The information required to be provided to registrants pursuant to Probate Code section 4802;

(8) The address where the completed form is to be filed;

(9) Contact information for obtaining, completing, or filing the form;

(10) Numbers, letters, lines or graphics that assist in understanding or completing the form;

(11) Space for the person completing the form to indicate:

(A) Whether the form is a new registration, an amendment to a prior registration, a revocation of a prior registration or notification regarding an amendment to or revocation of a previously-filed written advance health care directive;

(B) Whether the written advance health care directive or amendment to a previously-filed written advance health care directive is attached to the form or, in the alternative, whether the form provides notification of the intended place of deposit or safekeeping of a written advance health care directive or amendment to a written advance health care directive;

(C) The information specified in Probate Code section 4800(c), including name, social security number, driver's license number, or other individual identifying number established by law, if any, address, date and place of birth, and the name and telephone number of the agent and any alternative agent;

(D) Intended place of deposit or safekeeping of the written advance health care directive or amendment to the written advance health care directive to which the form relates, if applicable;

(E) The signature and printed name of the registrant;

(F) The date the form is signed by the registrant.

(12) Any other information or material required or specifically authorized by statute or regulation to be included on the form.

(1) The name, address and telephone number of the requestor;

(2) Credible evidence establishing the identity of the requestor. In determining whether the identity of the requestor is established by credible evidence, the Secretary of State may consider requestor’s use of business letterhead in making the request, a copy of a driver’s license or identification card issued by the California Department of Motor Vehicles, a copy of a United States passport, or copies of other credible identification documents;

(3) A statement by the requestor establishing his or her authority to receive the information requested;

(4) The identity of the individual for whom the information is requested. In establishing the identity of the individual for whom the information is requested, the Secretary of State may consider the presentation by the requestor of any information contained in or on the filed registration form, including a file number, date of birth, place of birth, social security number, driver’s license number or other identifying number; and

(5) A statement setting forth the reason the information is needed.