Durable Health Care Power Of Attorney And Health Care Treatment Instructions (Page 3 of 9) in pdf

You may choose whether you want your health care agent to be bound by your

instructions or whether you want your health care agent to be able to decide at the

time what course of treatment the health care agent thinks most fully reflects your

wishes and values.

If you are a woman and diagnosed as being pregnant at the time a health care

decision would otherwise be made pursuant to this form, the laws of this

Commonwealth prohibit implementation of that decision if it directs that life-sustaining

treatment, including nutrition and hydration, be withheld or withdrawn from you, unless

your attending physician and an obstetrician who have examined you certify in your

medical record that the life-sustaining treatment:

(1) will not maintain you in such a way as to permit the continuing

development and live birth of the unborn child;

(2) will be physically harmful to you; or

(3) will cause pain to you that cannot be alleviated by medication.

A physician is not required to perform a pregnancy test on you unless the physician has

reason to believe that you may be pregnant. Pennsylvania law protects your health

care agent and health care providers from any legal liability for following in good faith

your wishes as expressed in the form or by your health care agent's direction. It does

not otherwise change professional standards or excuse negligence in the way your

wishes are carried out. If you have any questions about the law, consult an attorney for

guidance.

This form and explanation is not intended to take the place of specific legal or medical

advice for which you should rely upon your own attorney and physician.

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. 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.

Durable Health Care Power Of Attorney And Health Care Treatment Instructions Page 3