Dpa.doc

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DURABLE POWER OF ATTORNEY
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE
(YOUR “AGENT”) BROAD POWERS, WHICH MAY INCLUDE POWERS TO MAKE DECISIONS
RELATING TO YOUR HEALTH CARE, WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY
YOU.

THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE
GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO
ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY.

YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME,
INCLUDING AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE
DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON
YOUR BEHALF TERMINATES YOUR AGENT’S AUTHORITY.

A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS
NOT ACTING PROPERLY.

THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE
EXPLAINED MORE FULLY IN 20 PA. C.S. CH. 56.

IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU
SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU.

I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS
CONTENTS.

________________________________________________________
That I, ________________________ of _________________ County, Pennsylvania, do constitute and appoint ________________________ of _________________ County, Pennsylvania to be my true
and lawful attorney having full power to act for me, and in my name, place and stead, but only in the event I
should become incompetent to give my consent to the following acts or things:
To authorize medical and surgical procedures. TO MAKE DECISIONS AS TO WHETHER OR NOT TO ENROLL ME AS A
HUMAN SUBJECT AS PART OF A BIOMEDICAL OR BEHAVIORAL RESEARCH PROJECT OR
STUDY, AND I GRANT THIS AUTHORITY UNDER THIS POWER OF ATTORNEY WITH THE
KNOWLEDGE THAT THERE MAY BE NO BENEFIT TO ME IF I BECOME A PARTICIPANT IN SUCH A
RESEARCH PROJECT OR STUDY AND THAT MY CONDITION MAY WORSEN AS A RESULT OF
SUCH PARTICIPATION.
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And I hereby ratify and confirm all that my said attorney shall lawfully do or cause to be done by virtue of the powers conferred by this Durable Power of Attorney, including anything done between its revocation by my death or by written instrument executed by me prior to my death, and notice of said revocation reaching my attorney; provided, however, that as against me and all persons claiming under me, everything which my attorney shall do or cause to be done under this Durable Power of Attorney subsequent to said notice of revocation reaching my said attorney shall be valid and effective in favor of any person claiming the benefit thereof who before the doing thereof shall not have had notice of such revocation. Any person may deal with my said attorney in full reliance that this Durable Power of Attorney has not been revoked upon the submission of written statement to that effect by my said attorney, accompanied by a signed counterpart hereof or by a reproduced copy of a signed counterpart thereof. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my seal this day of , 20___. PRINCIPAL: By:________________________________ WITNESS: By:________________________________ ___________________________________ Date:___________________ I, ________________________, HAVE READ THE ATTACHED DURABLE POWER OF ATTORNEY AND
AM THE PERSON IDENTIFIED AS THE AGENT FOR THE PRINCIPAL. I HEREBY ACKNOWLEDGE
THAT IN THE ABSENCE OF A SPECIFIC PROVISION TO THE CONTRARY IN THIS DURABLE
POWER OF ATTORNEY OR IN 20 PA. C.S., WHEN I ACT AS AGENT:
•
I SHALL EXERCISE THE POWERS FOR THE BENEFIT OF THE PRINCIPAL
I SHALL EXERCISE REASONABLE CAUTION AND PRUDENCE
________________________________________________________

Source: http://bhpadhc.org/yahoo_site_admin/assets/docs/Durable_Power_of_Attorney.131141550.pdf