Advance Healthcare Directive Form - Lancaster General Health

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ADVANCE HEALTHCARE DIRECTIVE FORM
This Advance Healthcare Directive form, created as a courtesy by Lancaster General
Health, consists of both a Healthcare Power of Attorney and a Living Will. This
document expresses my wishes and instructions for medical care when I am unable to
make medical decisions for myself.
My Personal Information
Name:
Street Address:
City, State, Zip Code:
Telephone: (
)
Date of Birth:
PART I: HEALTHCARE POWER OF ATTORNEY
Part I allows you to appoint a person to make healthcare decisions for you when you
are unable to make healthcare decisions for yourself. If you do not appoint a person in
this Part I, the person(s) identified in 20 Pa.C.S.A. §5461(d) are authorized to make
healthcare decisions for you.
A.
No Healthcare Agent
Initial the box below if you choose not to appoint a person to make healthcare decisions
for you when you are unable to make healthcare decisions for yourself. You are not
required to appoint a person. If you initial the box below, DO NOT complete Sections B,
C, D, and E, below.
I choose not to appoint a healthcare agent.
B.
My Healthcare Agent
I designate the person below to be my healthcare agent:
Name:
Street Address:
City, State, Zip Code:
Telephone: (
)
Cell Phone: (
)

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