Pennsylvania Medical Power of Attorney
This Pennsylvania Medical Power of Attorney is a legal document that allows an individual, known as the Principal, to designate another person, referred to as the Agent, to make healthcare decisions on their behalf should they become unable to make such decisions themselves. This document is designed in accordance with the Pennsylvania Consolidated Statutes, specifically under 20 Pa.C.S. §§ 5451 through 5465, also known as the Health Care Agents and Representatives Act.
It is crucial for the Principal to select an Agent whom they trust, as this individual will have the responsibility to make decisions that align with the Principal's wishes and values. Before completing this document, both the Principal and the Agent should have a thorough conversation about the Principal's desires regarding medical treatment and end-of-life care.
Complete the lines below to create your Pennsylvania Medical Power of Attorney.
Principal's Information:
- Full Name: ________________________
- Date of Birth: ________________________
- Address: ________________________
Agent's Information:
- Full Name: ________________________
- Relationship to Principal: ________________________
- Primary Phone Number: ________________________
- Alternate Phone Number: ________________________
- Address: ________________________
In the event that my primary Agent is unable or unwilling to serve, I hereby designate the following individual as my alternate Agent:
- Full Name: ________________________
- Relationship to Principal: ________________________
- Primary Phone Number: ________________________
- Alternate Phone Number: ________________________
- Address: ________________________
This Medical Power of Attorney grants the Agent the following powers, subject to any limitations specified:
- The authority to make any and all health care decisions on my behalf, including decisions to provide, withhold, or withdraw treatment, and decisions about the type of care, treatment, service, or procedure.
- The power to choose or change my healthcare providers and institutions.
- The power to access my medical records and disclose them as necessary to ensure the appropriate treatment.
- The right to refuse, consent to, or withdraw consent to any medical procedure or treatment based on what they believe are my wishes, including decisions related to life-sustaining treatment.
I understand that this document revokes any prior Medical Power of Attorney unless stated otherwise.
Principal's Signature: ________________________ Date: ________________________
Agent's Signature: ________________________ Date: ________________________
Alternate Agent's Signature (if applicable): ________________________ Date: ________________________
This document should be signed in the presence of two witnesses, who are not the Agent, who will also provide their signatures, names, and dates:
- Witness #1 Signature: ________________________ Date: ________________________
- Witness #1 Printed Name: ________________________
- Witness #2 Signature: ________________________ Date: ________________________
- Witness #2 Printed Name: ________________________