Durable Health Care Power Of Attorney (Page 3 of 4) in pdf

ADVANCE HEALTH CARE DIRECTIVE

DURABLE HEALTH CARE POWER OF ATTORNEY

I, ________________________________________________________ , of __________________________ County,

(Please print name )

Pennsylvania, appoint the person named below as my health care agent

to make health and personal care decisions for me.

I RIGHT TO HEALTH CARE INFORMATION

Effective immediately and continuously until my death or a signed, written revocation by me or someone

authorized to make health care treatment decisions for me, I authorize all health care providers or other

covered entities to disclose to my health care agent at his or her request any oral or written information

regarding my physical or mental health, including medical and hospital records and otherwise private,

privileged, protected or personal health information—such as defined and described in the federal

Health Insurance Portability and Accountability Act of 1996, regulations promulgated thereunder, and any

other federal, state or local laws and rules. Information disclosed by a health care provider or other covered

entity may be redisclosed and may no longer be subject to the privacy rules provided by 45 C.F.R. Pt. 164.

I POWERS OF HEALTH CARE AGENT

My health care agent shall have the following powers when my attending physician verifies that I

lack the ability to understand, make or communicate a choice regarding a health or personal care

decision. My health care agent may not delegate this authority to make decisions.

Cross out and initial those powers that you do not want to give:

______

1. To authorize, withhold or withdraw medical care and surgical procedures.

______

2. To authorize, withhold or withdraw nutrition (food) or hydration (water) medically supplied by tube

through my nose, stomach, intestines, arteries or veins.

______

3. To authorize my admission to or discharge from a medical, nursing, residential or similar facility and to

make agreements for my care and health insurance for my care, including hospice and/or palliative care.

______

4. To hire and fire medical, social service and other support personnel responsible for my care.

______

5. To take any legal action necessary to do what I have directed.

______

6. To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order, including

an out-of-hospital DNR order, and sign any required documents and consents.

I APPOINTMENT OF HEALTH CARE AGENT

(If you do not name a health care agent, a family member or an adult who knows your preferences and values will be

asked for help in determining your treatment wishes). I appoint the following person as my health care agent:

_____________________________________________________________________________________

Health Care Agent (Name and relationship)

_____________________________________________________________________________________

Address

_____________________________________________________________________________________

Telephone Number (Home and Work)

E-mail

If my health care agent is not readily available, or is my spouse and an action for divorce is filed between us after this

date, I appoint the following in the order indicated. (It is helpful, but not required to name alternative health care agents.)

_____________________________________________________________________________________

First Alternative Health Care Agent (Name and relationship)

_____________________________________________________________________________________

Address

_____________________________________________________________________________________

Telephone Number (Home and Work)

E-mail

_____________________________________________________________________________________

Second Alternative Health Care Agent (Name and relationship)

_____________________________________________________________________________________

Address

_____________________________________________________________________________________

Telephone Number (Home and Work)

E-mail

I GUIDANCE TO HEALTH CARE AGENT

If I have an end-stage medical condition or other extreme irreversible medical condition, my goals in making

medical decisions are as follows (insert personal priorities, such as comfort, care, preservation of mental function, etc.):

_____________________________________________________________________________________

I SEVERE BRAIN DAMAGE OR BRAIN DISEASE

I consider suffering from severe and irreversible brain damage or brain disease with no realistic hope of

significant recovery to be intolerable, and aggressive medical care for it to be burdensome. I therefore request

my health care agent to respond to any intervening life-threatening conditions in such circumstances as I

have directed for an end-stage medical condition or a state of permanent unconsciousness.

Durable Health Care Power Of Attorney Page 3

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