Commonwealth of Pennsylvania – Act 169 of 2006
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 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 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.
The remainder of this document will take effect when and only when I lack the ability to understand, make or
communicate a choice regarding a health or personal care decision as verified by my attending physician. My health
care agent may not delegate the authority to make decisions.
My health care agent has all of the following powers subject to the health care treatment instructions that follow in
Part III (cross out any powers you do not want to give your health care agent):
1. To authorize, withhold or withdraw medical care and surgical procedures.
2. To authorize, withhold or withdraw nutrition (food) or hydration (water) medically supplied
by tube through my nose, stomach, intestines, arteries or veins.
3. To authorize my admission to or discharge from a medical, nursing, residential or similar
facility and to make agreements for my care and health insurance for my care, including
hospice and/or palliative care.
4. To hire and fire medical, social service and other support personnel responsible for my care.
5. To take any legal action necessary to do what I have directed.
6. To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order,
including an out-of-hospital DNR order, and sign any required documents and consents.
Appointment of Health Care Agent
I appoint the following health care agent:
Health Care Agent (Name and relationship):
Telephone Number: Home Work
Commonwealth of Pennsylvania – Act 169 of 2006
If you do not name a health care agent, health care providers will ask your family or an adult who knows your
preferences and values for help in determining your wishes for treatment. Note that 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.
If my health care agent is not readily available or if my health care agent is my spouse and an action for divorce
is filed 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.)
irst Alternativ
e Health Care Agent (name and relationship):
Telephone Numbers: Home Work
Second Alternativ
e Health Care Agent (name and relationship):
Telephone Number: Home Work
Guidance for Health Care Agent (optional)
If I have an end-stage medical condition or other extreme irreversible medical condition, my goals in making
medical decisions are as follows (insert your personal priorities such as comfort, care, preservation of mental
function, etc.):
Severe Brain Damage or Brain Disease
If I should suffer from severe and irreversible brain damage or brain disease with no realistic hope of significant
recovery, I would consider such a condition intolerable and the application of aggressive medical care to be
burdensome. I therefore request that my health care agent respond to any intervening (other and separate) life-
threatening conditions in the same manner as directed for an end-stage medical condition or state of permanent
unconsciousness as I have indicated below.
I agree
Initials I disagree
Commonwealth of Pennsylvania – Act 169 of 2006
Health Care Agent’s Use of Instructions
(Initial one option only)
My health care agent must follow these instructions.
These instructions are only guidance. My health care agent shall have final say and may override any
of my instructions. (Indicate any exceptions)
If I did not appoint a health care agent, these instructions shall be followed.
Legal Protection
Pennsylvania law protects my health care agent and health care providers from any legal liability for their good faith
actions in following my wishes as expressed in this form or in complying with my health care agents direction. On
behalf of myself, my executors and heirs, I further hold my health care agent and my health care providers harmless
and indemnify them against any claim for their good faith actions in recognizing my health care agent’s authority or
in following my treatment instructions.
Organ Donation (Inital one option only.)
I consent to donate my organs and tissues at the time of my death for the purpose of transplant,
medical study or education. (Insert any limitations you desire on donation of specific organs or
tissues or uses for donation of organs and tissues.)
I do not consent to donate my organs or tissues at the time of my death.
Having carefully read this document, I have signed it this day of
, 20 , revoking all previous health care powers of attorney and health care
treatment instructions.
(Sign full name here for health care power of attorney and health care treatment instructions.)
click to sign
click to edit
click to sign
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Commonwealth of Pennsylvania – Act 169 of 2006
Two witnesses at least 18 years of age are required by Pennsylvania law and should witness your signature in each
other’s presence. A person who signs this document on behalf of and at the direction of a principal may not be a
witness. (It is preferable if the witnesses are not your heirs, nor your creditors, nor employed by any of your health
care providers.)
Notarization (optional)
(Notarization of document is not required by Pennsylvania law, but if the document is both witnessed and notarized,
it is more likely to be honored by the laws of some other states.)
On this
day of , 20 , before me personally appeared
the aforesaid declarant and principal, to me known to be the person described in and who executed the foregoing
instrument and acknowledged that he/she executed the same as his/her free act and deed.
In witness whereof, I have hereunto set my hand and affixed my official seal in the County of
, State of the day and year first above written.
Notary Public My commission expires