Pennsylvania Medical Power of Attorney Template
This Medical Power of Attorney is designed for use in the state of Pennsylvania. It allows you to appoint someone to make medical decisions on your behalf if you become unable to do so.
Principal Information:
- Name: ______________________________
- Address: ____________________________
- City, State, Zip: ____________________
- Date of Birth: ______________________
Agent Information:
- Name: ______________________________
- Address: ____________________________
- City, State, Zip: ____________________
- Phone Number: ______________________
Effective Date:
This Medical Power of Attorney becomes effective when I am unable to make my own medical decisions, as determined by my attending physician.
Authority Granted:
I grant my agent the authority to make healthcare decisions on my behalf, including but not limited to:
- Choosing healthcare providers and facilities.
- Consenting to or refusing medical treatment.
- Accessing my medical records.
- Making decisions about life-sustaining treatment.
Limitations:
Any limitations on my agent's authority should be specified here: ________________________________.
Signatures:
By signing below, I affirm that I am of sound mind and am voluntarily appointing my agent to act on my behalf in medical matters.
Principal's Signature: ___________________________ Date: _______________
Witness Signature: _____________________________ Date: _______________
Witness Signature: _____________________________ Date: _______________
This document must be signed in the presence of two witnesses who are not related to you or named as your agent.
It is advisable to keep this document in a safe place and share copies with your agent and healthcare providers.