Looking for a Medical Power Of Attorney Form Templates? Download it for free!

Form Rev 133c7e0 - Pa Power Of Attorney For My Health Care - Medical Power Of Attorney Page 2

WHAT WILL YOUR AGENT'S POWERS BE?

My agent knows my goals and wishes based on our conversations and on any other guidance I may have

written. My agent has full authority to make decisions for me about my health care according to my goals

and wishes. If the choice I would make is unclear, then my agent will decide based on what he or she

believes to be in my best interests. My agent’s authority to interpret my wishes is intended to be as broad

as possible, and includes the following authority:

1. To agree to, refuse, or withdraw consent to any type of medical care, treatment, surgical procedures,

tests, or medications. This includes decisions about using mechanical or other procedures that

affect any bodily function, such as artificial respiration, artificially supplied nutrition and hydration

(that is, tube feeding), cardiopulmonary resuscitation, or other forms of medical support, even if

deciding

stop

withhold

treatment

could

would

result

death. ______ (Principal’s initials)

2. To have access to medical records and information to the same extent that I am entitled to, including

the right to disclose health information to others.

3. To authorize my admission to or discharge (even against medical advice) from any hospital, nursing

home, residential care, assisted-living or similar facility or service.

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

5. To decide about organ and tissue donations, autopsy, and the disposition of my remains as the law

permits.

6. To take any other action necessary to do what I authorize here, including signing waivers or other

documents, pursuing any dispute resolution process, or taking legal action in my name.

WHEN WILL THIS POWER BE EFFECTIVE?

This Power of Attorney for My Health Care will become effective during any time in which, in the opinion

of my agent and attending physician, I am unable to make or communicate a choice about a particular

health care decision.

OTHER PROVISIONS

1. Health care providers can rely on my agent. No one who relies in good faith on any representations by

my agent or back-up agent will be liable to me, my estate, my heirs or assigns, for recognizing the agent's

authority.

2. I cancel any previous power of attorney for health care that I may have signed.

3. I intend this power of attorney to be universal; it is valid in any jurisdiction in which it is presented.

Medical Power of Attorney (Rev. 133C7E0)

2 / 4

Form Rev 133c7e0 - Pa Power Of Attorney For My Health Care - Medical Power Of Attorney Page 2