Durable Health Care Power Of Attorney And Health Care Treatment Template (Page 7 of 8) in pdf

Durable Health Care Power Of Attorney And Health Care Treatment Template Page 7

My health care agent shall have final say and may override any of my instructions. (Indicate any

exceptions.)

If I did not appoint a health care agent, these instructions shall be followed.

LEGAL PROTECTION

Pennsylvania law protects my health care agent and health care providers from any legal liability

for their good faith actions in following my wishes as expressed in this form or in complying

with my health care agent's direction. On behalf of myself, my executors and heirs, I further

hold my health care agent and my health care providers harmless and indemnify them against

any claim for their good faith actions in recognizing my health care agent's authority or in fol-

lowing my treatment instructions.

ORGAN DONATION (INITIAL ONE OPTION ONLY.)

_____ I consent to donate my organs and tissues at the time of my death for the purpose of

transplant, medical study or education. (Insert any limitations you desire on donation of specific

organs or tissues or uses for donation of organs and tissues.)

_____ I do not consent to donate my organs or tissues at the time of my death.

Having carefully read this document, I have signed it this _____ day of ___________________,

20__, revoking all previous health care powers of attorney and health care treatment instructions.

SIGNED: _____________________________________________________________________

(SIGN FULL NAME HERE FOR HEALTH CARE POWER OF ATTORNEY

AND HEALTH CARE TREATMENT INSTRUCTIONS)

WITNESS: ____________________________________________________________________

Two witnesses at least 18 years of age are required by Pennsylvania law and should witness

your signature in each other's presence. A person who signs this document on behalf of and at

the direction of a principal may not be a witness. (It is preferable if the witnesses are not your

heirs, nor your creditors, nor employed by any of your health care providers.)

Durable Health Care Power Of Attorney And Health Care Treatment Template Page 7