Durable Power of Attorney for Health Care, Pennsylvania

PENNSYLVANIA DURABLE POWER OF ATTORNEY

FOR HEALTH CARE

I, ____________________________________________________________________,

appoint _______________________________________________________________

             (Name)                                                                                   (Work Phone)

            _______________________________________________________________

            (Address)                                                                                (Home Phone)

as my attorney-in-fact or agent to make health and personal care decisions for me if I become incapable of making my own decisions.  If the person named above is unable to serve as my agent for any reason, I appoint an alternate to serve as my agent:

_______________________________________________________________

(Name)                                                                                    (Work Phone)

_______________________________________________________________

(Address)                                                                                (Home Phone)

This Durable Power of Attorney for Health Care shall become effective upon my incapacity.  I grant the following powers to my agent:

1. To authorize my admission to or discharge from any medical, nursing, residential, or similar facility and to enter into agreements for my care.

2. To authorize, refuse, or withdraw consent to any and all types of medical and surgical procedures, care, or treatment, including, but not limited to, nutrition and hydration administered by artificial or invasive means.

I have discussed my wishes concerning my health care with my agent, who shall follow my directions to the extent known.  If my agent is unable to determine what I would want, then my agent shall make a decision based upon what he or she believes to be in my best interests. 

I revoke any prior power of attorney for health care.

My signature below means that I understand this document and intend this grant of powers to my agent to be legally binding.

__________________________________

(Signature)                              (Date)

__________________________________

(Witness)                                (Date)

__________________________________

(Witness)                                (Date)