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 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.
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