Pennsylvania Code § 20-5465

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A health care power of attorney may be in any written form identifying the principal, appointing a health care agent and declaring that the principal authorizes the health care agent to make health care decisions on behalf of the principal. An example of a health care power of attorney appears in the combined form set forth in Subchapter D (relating to combined form).
SUBCHAPTER D
COMBINED FORM
Sec.
5471. Example.

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