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Pennsylvania Durable Health Care Power of Attorney Form 2


Pennsylvania Durable Health Care Power of Attorney Form 2
Pennsylvania Durable Health Care Power of Attorney Form 2
I. HEALTH CARE POWER OF ATTORNEY
AND
II. HEALTH CARE TREATMENT INSTRUCTIONS IN THE EVENT OF END-STAGE
MEDICAL CONDITION OR PERMANENT UNCONSCIOUSNESS
(“LIVING WILL”)
PART I - 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 whenever
I cannot understand, make or communicate a choice regarding a health care decision as determined by my
doctor or whenever I personally inform my doctor. My agent may not delegate the authority to make decisions.
APPOINTMENT OF HEALTH CARE AGENT:
I appoint the following health care agent: You may not appoint your doctor or other health care provider as your health
care agent unless related to you by blood, marriage or adoption.
Health Care Agent: __________________________________________________________________________
(Name and Relationship)
Address: Telephone Numbers
____________________________________________________________________________________ Home
____________________________________________________________________________________ Work
E-Mail: ______________________________________________________________________________ Cell
If my health care agent is not reasonably available, or is unable or unwilling to act in a timely manner, or if my health care
agent is my spouse and an action for divorce is led by either of us after the date of this document, I appoint the person
or persons named below in the order named. (It is helpful, but not required, to name alternative health care agents).
ADVANCE HEALTH CARE DIRECTIVE PAGE 1
SEPARATE HIPAA AUTHORIZATION EFFECTIVE IMMEDIATELY
Eective 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 agents 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 dened and described
in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), the regulations issued under
HIPAA 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 these privacy rules.
APPROVED BY: Allegheny County Bar Association
_______________________________________
Name and Relationship
_______________________________________
Address
_______________________________________
City State Zip
_______________________________________
Home Phone Cell Phone
_______________________________________
Work Phone E-Mail
2
ND
ALTERNATE
_______________________________________
Name and Relationship
_______________________________________
Address
_______________________________________
City State Zip
_______________________________________
Home Phone Cell Phone
_______________________________________
Work Phone E-Mail
1
ST
ALTERNATE
Pennsylvania Durable Health Care Power of Attorney Form 2
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