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Printable Medical Power of Attorney Template for Pennsylvania

The Pennsylvania Medical Power of Attorney form is a legal document that allows individuals to designate someone they trust to make healthcare decisions on their behalf in the event they become unable to communicate their wishes. This form is essential for ensuring that personal medical preferences are honored, even when one cannot speak for themselves. By using this form, individuals can provide clarity and peace of mind regarding their medical care.

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Outline

When it comes to making healthcare decisions on behalf of a loved one, the Pennsylvania Medical Power of Attorney form serves as an essential tool. This document empowers an individual, known as the agent, to make medical choices for someone who is unable to do so themselves, ensuring that their healthcare preferences are respected even in challenging circumstances. The form outlines the specific powers granted to the agent, which may include decisions about medical treatments, procedures, and end-of-life care. It is crucial for individuals to consider appointing a trusted person who understands their values and wishes, as this can significantly impact the quality of care received. Additionally, the Pennsylvania Medical Power of Attorney form must be signed in the presence of a notary or two witnesses to ensure its validity. Having this document in place not only provides peace of mind but also helps to avoid potential conflicts among family members during difficult times. Understanding its importance and the steps to complete it can empower individuals to take control of their healthcare decisions and support their loved ones in navigating these sensitive issues.

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Pennsylvania Medical Power of Attorney

This Medical Power of Attorney is granted in accordance with the Pennsylvania Health Care Agents and Representatives Act, empowering an individual to make health care decisions on another’s behalf under specific circumstances.

Principal Information:

Full Name: ___________________________
Date of Birth: ________________________
Address: _____________________________
City: ________________________________
State: Pennsylvania
Zip Code: ____________________________

Agent Information:

Full Name: ___________________________
Relationship to Principal: _____________
Primary Phone Number: ________________
Alternate Phone Number: ______________
Address: _____________________________
City: ________________________________
State: _______________________________
Zip Code: ____________________________

By this document, I grant my selected agent broad powers to make health care decisions for me, including but not limited to:

Consenting or refusing consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
Selecting or discharging health care providers and institutions.
Agreeing to a plan of health care that includes instructions for my future health care.
Making decisions about organ donation, autopsy, and disposition of the body.

Special Instructions:

____________________________________________________________________________________________

This Medical Power of Attorney becomes effective when my attending physician certifies in writing that I lack the ability to make or communicate health care decisions.

I understand that I retain the right to revoke this authorization in whole or in part at any time, provided I do so in writing, the revocation is signed, and it is communicated to my attending physician.

Principal's Signature: ___________________________ Date: ________________

Agent's Signature: ___________________________ Date: ________________

Witness Declaration:

I declare that the principal appears to be of sound mind and free from duress at the time of signing this document, and that they affirmed they are aware of the nature of the document and signed it freely and voluntarily.

Witness 1 Signature: ___________________________ Date: ________________

Witness 2 Signature: ___________________________ Date: ________________

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Document Data

Fact Name	Description
Definition	A Pennsylvania Medical Power of Attorney allows an individual to appoint someone to make healthcare decisions on their behalf if they become unable to do so.
Governing Law	This form is governed by the Pennsylvania Consolidated Statutes, Title 20, Chapter 54.
Eligibility	Any competent adult in Pennsylvania can create a Medical Power of Attorney.
Agent Requirements	The appointed agent must be at least 18 years old and cannot be the patient's healthcare provider or an employee of the healthcare provider.
Revocation	The principal can revoke the Medical Power of Attorney at any time, as long as they are still competent.
Durability	This document remains in effect even if the principal becomes incapacitated, unless stated otherwise.
Witness Requirements	The form must be signed by the principal and witnessed by two individuals or notarized to be valid.

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