2010 Pennsylvania Code
Title 20 - DECEDENTS, ESTATES AND FIDUCIARIES
Chapter 58 - Mental Health Care
5833 - Form.

     § 5833.  Form.
        (a)  Requirements.--A mental health power of attorney must do
     the following:
            (1)  Identify the principal and appoint the mental health
        care agent.
            (2)  Declare that the principal authorizes the mental
        health care agent to make mental health care decisions on
        behalf of the principal.
        (b)  Optional provisions.--A mental health power of attorney
     may:
            (1)  Describe any limitations that the principal imposes
        upon the authority of the mental health care agent.
            (2)  Indicate the intent of the principal regarding the
        initiation, continuation or refusal of mental health
        treatment.
            (3)  Nominate a guardian of the person of the principal
        as provided in Subchapter C of Chapter 55 (relating to
        appointment of guardian; bonds; removal and discharge).
            (4)  Contain other provisions as the principal may
        specify regarding the implementation of mental health care
        decisions and related actions by the mental health care
        agent.
        (c)  Written form.--A mental health power of attorney may be
     in the following form or any other written form identifying the
     principal, appointing a mental health care agent and declaring
     that the principal authorizes the mental health care agent to
     make mental health care decisions on behalf of the principal:
                     Mental Health Power of Attorney
        I,                  , having the capacity to make mental
        health decisions, authorize my designated health care agent
        to make certain decisions on my behalf regarding my mental
        health care. If I have not expressed a choice in this
        document, I authorize my agent to make the decision that my
        agent determines is the decision I would make if I were
        competent to do so.
        I understand that mental health care includes any care,
        treatment, service or procedure to maintain, diagnose, treat
        or provide for mental health, including any medication
        program and therapeutic treatment. Electroconvulsive therapy
        may be administered only if I have specifically consented to
        it in this document. I will be the subject of laboratory
        trials or research only if specifically provided for in this
        document. Mental health care does not include psychosurgery
        or termination of parental rights.
        I understand that my incapacity will be determined by
        examination by a psychiatrist and one of the following:
        another psychiatrist, psychologist, family physician,
        attending physician or mental health treatment professional.
        Whenever possible, one of the decision makers shall be one of
        my treating professionals.
        A.  Designation of agent.
        I hereby designate and appoint the following person as my
        agent to make mental health care decisions for me as
        authorized in this document:
                    (Insert name of designated person)
        Signed:
        (My name, address, telephone number)
        (Witnesses' signatures)
        (Names, addresses, telephone numbers of witnesses)
        Agent's acceptance:
        I hereby accept designation as mental health care agent for
        (Insert name of declarant)
        Agent's signature:
        (Insert name, address, telephone number of designated person)
        B.  Designation of alternative agent.
        In the event that my first agent is unavailable or unable to
        serve as my mental health care agent, I hereby designate and
        appoint the following individual as my alternative mental
        health care agent to make mental health care decisions for me
        as authorized in this document:
        (Insert name of designated person)
        Signed:
        (Witnesses' signatures)
        (Names, addresses, telephone numbers of witnesses)
        Alternative agent's acceptance:
        I hereby accept designation as alternative mental health care
        agent for
        (Insert name of declarant)
        Alternative agent's signature:                  .
        (Insert name, address, telephone number)
        C.  When this power of attorney becomes effective.
        This power of attorney will become effective at the following
        designated time:
        ( )  When I am deemed incapable of making mental health care
        decisions.
        ( )  When the following condition is met:
                             (List condition)
        D.  Authority granted to my mental health care agent.
        I hereby grant to my agent full power and authority to make
        mental health care decisions for me consistent with the
        instructions and limitations set forth in this power of
        attorney. If I have not expressed a choice in this power of
        attorney, I authorize my agent to make the decision that my
        agent determines is the decision I would make if I were
        competent to do so.
        E.  Treatment preferences.
            1.  Choice of treatment facility.
        ( )  In the event that I require commitment to a psychiatric
        treatment facility, I would prefer to be admitted to the
        following facility:
                    (Insert name and address of facility)
        ( )  In the event that I require commitment to a psychiatric
        treatment facility, I do not wish to be committed to the
        following facility:
                  (Insert name and address of facility)
        I understand that my physician may have to place me in a
        facility that is not my preference.
            2.  Preferences regarding medications for psychiatric
        treatment.
        ( )  I consent to the medications that my agent agrees to
        after consultation with my treating physician and any other
        persons my agent considers appropriate.
        ( )  I consent to the medications that my agent agrees to,
        with the following exception or limitation:
                      (List exception or limitation)
        This exception or limitation applies to generic, brand name
        and trade name equivalents.
        ( )  My agent is not authorized to consent to the use of any
        medications.
            3.  Preferences regarding electroconvulsive therapy
        (ECT).
        ( )  My agent is authorized to consent to the administration
        of electroconvulsive therapy.
        ( )  My agent is not authorized to consent to the
        administration of electroconvulsive therapy.
            4.  Preferences for experimental studies or drug trials.
        ( )  My agent is authorized to consent to my participation in
        experimental studies if, after consultation with my treating
        physician and any other individuals my agent deems
        appropriate, my agent believes that the potential benefits to
        me outweigh the possible risks to me.
        ( )  My agent is not authorized to consent to my
        participation in experimental studies.
        ( )  My agent is authorized to consent to my participation in
        drug trials if, after consultation with my treating physician
        and any other individuals my agent deems appropriate, my
        agent believes that the potential benefits to me outweigh the
        possible risks to me.
        ( )  My agent is not authorized to consent to my
        participation in drug trials.
            5.  Additional information and instructions.
        Examples of other information that may be included:
            Activities that help or worsen symptoms.
            Type of intervention preferred in the event of a crisis.
            Mental and physical health history.
            Dietary requirements.
            Religious preferences.
            Temporary custody of children.
            Family notification.
            Limitations on release or disclosure of mental health
                records.
            Other matters of importance.
        F.  Revocation.
        This power of attorney may be revoked in whole or in part at
        any time, either orally or in writing, as long as I have not
        been found to be incapable of making mental health decisions.
        My revocation will be effective upon communication to my
        attending physician or other mental health care provider,
        either by me or a witness to my revocation, of the intent to
        revoke. If I choose to revoke a particular instruction
        contained in this power of attorney in the manner specified,
        I understand that the other instructions contained in this
        power of attorney will remain effective until:
            (1)  I revoke this power of attorney in its entirety;
            (2)  I make a new mental health power of attorney; or
            (3)  two years after the date this document was executed.
        G.  Termination.
        I understand that this power of attorney will automatically
        terminate two years from the date of execution unless I am
        deemed incapable of making mental health care decisions at
        the time the power of attorney would expire.
        H.  Preference as to a court-appointed guardian.
        I understand that I may nominate a guardian of my person for
        consideration by the court if incapacity proceedings are
        commenced pursuant to 20 Pa.C.S. § 5511. I understand that
        the court will appoint a guardian in accordance with my most
        recent nomination except for good cause or disqualification.
        In the event a court decides to appoint a guardian, I desire
        the following person to be appointed:
        (Insert name, address, telephone number of designated person)
        ( )  The appointment of a guardian of my person will not give
        the guardian the power to revoke, suspend or terminate this
        power of attorney.
        ( )  Upon appointment of a guardian, I authorize the guardian
        to revoke, suspend or terminate this power of attorney.
        I am making this power of attorney on the (insert day) of
        (insert month), (insert year).
        My signature:
        (My name, address, telephone number)
        Witnesses' signatures:
        (Names, addresses, telephone numbers of witnesses)
        If the principal making this power of attorney is unable to
        sign it, another individual may sign on behalf of and at the
        direction of the principal.
        Signature of person signing on my behalf:
        (Name, address, telephone number)