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Pennsylvania Health Care Power of Attorney Form

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The Pennsylvania Health Care Power Of Attorney is Part II of the official Advance Directive provided by the Commonwealth. This PAPERWORK has been developed so the Principal who issues it can name his or her Health Care Agent and document his or her preferences. Generally speaking, the Health Care Agent is someone close to the Principal such as his or her spouse or a close relative. Even a close friend of the Principal can be named as the Health Care Agent so long as this person has demonstrated his or her trustworthiness and capability when acting in such a role. This is imperative to the function of this document. Afterall the goal of this document is to deliver the security of knowing that someone the Principal loves and trusts will handle medical decisions if he or she has been rendered unable to communicate. It is strongly recommended the Principal and Health Care Agent have a detailed discussion regarding the contents of this paperwork before it is executed.

Definition – § 5422

LawsChapter 54 Subchapter C (§ 5441 to § 5447)

Living Will – Part III of the Advance Directive which grants the patient the right to give instructions to the hospital about their right to a natural death and the types of medication they desire in such a situation.

Durable (Financial) Power of Attorney – Using this document will enable your agent to carry out transactions on your behalf regarding your property and assets.

How to Write

1 – Access And Fill Out This Template To Name An Individual As A Health Care Agent In Pennsylvania

The form on this page will definitively appoint a person with the Power to make Health Care Decisions and Take Actions with a Principal’s Medical Care should the Principal be unable to communicate.

2 – The Principal Must Be Introduced In The First Paragraph

The person who wishes to grant Health Care Powers to an Agent must have his or her Name recorded on the first available empty line in the introduction.The second available empty line will require a basic verification of the Principal’s Identity through the presentation of his or her Address.

3 – Review The Powers Being Granted To The Agent And Identify Him Or Her

The basic Decisions and Actions a Health Care Agent will have the Power to conduct on the Principal’s behalf will need to be reviewed before proceeding. Locate the numbered list of Principal Authority on the first page. Any of these Principal Powers can be removed or deleted before the Principal signs this Directive, but not after he or she does. Thus, the Principal should go through this list. By default it will give the Health Care Agent the Authority to withhold/withdraw medical care and surgical procedures, withhold/withdraw artifical nutrition and hydration, Admit or Discharge the Principal from Health Care Facilities (i.e. Medical, nursing, residential, hospice, etc.), hire/fire individuals responsible for the Principal’s Health (i.e. Social Service, Support Personel), engage in Legal Action to enforce the Principal’s wishes, and request the Principal’s Physician to issue a DNR (Do Not Resucitate).If any list item contains a definition of actions the Health Care Agent should not be allowed to engage in, cross it out with a horizontal line or delete it using the appropriate software.Next it will be time to present the Identity of the Health Care Agent. This task will be handled in the section labeled “Appointment Of Health Care.” Here several lines will be provided to effectively disclose the identity of the person the Principal wishes to name as his or her Health Care Agent. Find the line following the words “I Appoint The Following Health Care Agent,” then enter the Full Name of the Health Care Agent. This statement will act as a formal declaration of the principal.Re-enter the Health Care Agent’s Name on the blank space following the words “Health Care Agent (Name And Relationships)” along with the role the Health Care Agent plays in the Principal’s life (i.e. “Cousin,” “Close Friend,” “Daughter”).The next several blank lines will be devoted purely for the purpose of defining the Health Care Agent’s Location and Contact Information. Enter his or her Address on the “Address” line.Next using the two spaces (labeled “Home” and “Work”) following the label “Telephone Number,” enter Health Care Agent’s Home Telephone Number and Work NumberThe blank line labeled “E-Mail” requires the E-Mail Address of the Health Care Agent entered on it. This should be an up-to-date account that is regularly monitored by the Health Care Agent.If the Health Care Agent is not available, cannot wield Principal Power, or will not live up to his or her assigned role then it may be considered wise to have an Alternate Health Care Agent set-up to assume Principal Power. To do this, locate the two paragraph beginning with the term “If You Do Not Name A Health Care Agent…” then use the next portions of this area to declare a “First Alternative Health Care Agent (Name And Relationship)” on the first blank line. (i.e. Johnathan Doe, Son). Below this, enter the First Alternative Health Care Agent’s Address, Telephone Numbers (Home and Work), and E-Mail Address.In the portion of this document beginning with the line labeled “Second Alternative Health Care Agent (Name And Relationship),” record the Full Name of the Second Alternative Health Care Agent along with how this individual is related to the Principal (i.e. Janet Doe, Daughter). Then, on the next few blank lines, document this entity’s Address, Home Telephone Number, Work Telephone Number, and Email Address. Keep in mind that neither Alternative First or Second Health Care Agents will access Principal Power only through succession. That is, the Health Care Agent must be unavaible so the First Alternative Health Care Agent may use Principal Power.

4 – Prepare And Report The Principal Directives the Health Care Agent Must Obey

Locate the area titled “Guidance For Health Care Agent (Optional).” In this area, using the blank lines under the word “Goals,” the Principal may address the Health Care Agent and anyone privy to this document his or her exact preferences when medical events occur and her or she cannot communicate or is in a long-term vegetative state. Generally, it is recommended the Principal speak freely. For instance he or she may have religious concerns when it comes to Medical Care or he or she may wish the Health Care Agent to withhold/withdraw artificial nutrition and hydration(food and water through a tube) only under certain conditions. The Principal may address any issue in this area and provide any Directive that he or she expects the Health Care Agent and Medical Professionals to follow so long as such Directives are legal.The next area requiring that may be attended to (at the Principal’s discretion) is titled “Severe Brain Damage Or Brain Disease.” There will be two blank lines labeled “I Agree” and “I Disagree” one of which the Principal must initial. If the Principal is in a state described in this statement (suffering from Brain Damage or Disease that is overly burdensome, painful, and terminal) and wishes the Health Care Agent to respond to this condition as if it were an “End-State Medical Condition” or “Permanent Unconsciousness,” then he or she should initial the first blank line. If the Principal does not wish the Health Care Agent to treat such a condition as an End-Stage Event, then he or she should initial the second blank line.

5 – Present The Principal’s Decisions On A Couple Of Additional Issues

In the section labeled “Health Care Agent’s Use Of Instructions” the Principal can indicate how he or she wishes the Health Care Agent to treat these instructions. If the Health Care Agent should follow this Directive in a strict and unyielding manner regardless of any complication, the Principal must initial the first blank line in this section.If the Principal wishes these instructions to act as only as a sort of guidance and prefers the Agent to have the Power to override these instructions, then he or she should initial the second blank line. If there are any exceptions to this preference they should be documented using the area provided.One final Directive that may be address, if desired by the Principal, is titled “Organ Donation (Initial One Option Only).” If the Principal intends to consent to an Organ Donation or any other Anatomical Gifts, then he or she should initial the first blank line here. Any limitations, restrictions, or conditions may be listed in the area provided.If the Principal does not wish to make any Anatomical Gifts or Donate Any Organs, then he or she should intitial the blank line corresponding to the statement “I Do Not Consent To Donate…”

6 – To Deliver The Principal Power To The Health Care Agent, The Principal Must Sign His Or Her Name

This document will conclude with the Dated and Witnessed Notarized Signature of the Principal. Only the Principal, Two Witnesses, and a Notary Public. The first task before the Principal here will be to enter the Calendar Day, Month, and Year that he or she is signing this document.Below this will be a long blank line the Principal must sign. The Principal must sign his or her Full Name here.Each Witness must also provide his or her Signature at the time of the Principal Signing. This task should be performed on the blank lines labeled “Witness.” Each Witness must sign a unique line in this area.Finally, the “Notarization (Optional)” area has been provided so the Notary Public subjecting this Directive to the Notarization process. While this area is optional, it is generally recommended the execution of such delegations is notarized.


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