Durable Health Care Power Of Attorney And Health Care Treatment Template (Page 4 of 8) in pdf

PART II

DURABLE HEALTH CARE POWER OF ATTORNEY

I,___________________, of_______________County, Pennsylvania, appoint the person named

below to be my health care agent to make health and personal care decisions for me.

Effective immediately and continuously until my death or revocation by a writing signed 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, upon my agent's

request, any information, oral or written, regarding my physical or mental health, including, but

not limited to, medical and hospital records and what is otherwise private, privileged, protected

or personal health information, such as health information as defined and described in the

Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat.

1936), the regulations promulgated thereunder and any other State or local laws and rules. Infor-

mation 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.

The remainder of this document will take effect when and only when I lack the ability to under-

stand, make or communicate a choice regarding a health or personal care decision as verified by

my attending physician. My health care agent may not delegate the authority to make decisions.

MY HEALTH CARE AGENT HAS ALL OF THE FOLLOWING POWERS SUBJECT TO

THE HEALTH CARE TREATMENT INSTRUCTIONS THAT FOLLOW IN PART III

(Cross out any powers you do not want to give your health care agent):

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.

APPOINTMENT OF HEALTH CARE AGENT

I appoint the following health care agent:

Health Care Agent: _____________________________________________________________

(Name and relationship)

Address: ______________________________________________________________________

Telephone Number: Home _________________________ Work ________________________

E-mail: _______________________________________________________________________

IF YOU DO NOT NAME A HEALTH CARE AGENT, HEALTH CARE PROVIDERS WILL

ASK YOUR FAMILY OR AN ADULT WHO KNOWS YOUR PREFERENCES AND VALUES

Durable Health Care Power Of Attorney And Health Care Treatment Template Page 4