Pennsylvania Medical Power of Attorney (POA) Form

The Medical Power of Attorney (MPA) is a document that allows a person to choose a reliable agent or attorney who will act in critical conditions and situations of crisis. If a person (or a declarant) becomes disabled and unconscious or suddenly faces a vegetative state, coma, or a similar physical condition, the agent appointed by a medical power of attorney form will take care of the decisions regarding the declarant.

The agent or attorney will be responsible for continuing or stopping the treatment, accepting or refusing it for the declarant. This is a vital document in the United States, especially for the people that have already gotten sick and have severe disease or those who are older than a certain age. Also, the MPA form lets the agent or attorney act in case of an accident when the victim has had serious injuries and has become disabled.

Pennsylvania power of attorney forms – look into several other powers of attorney common in Pennsylvania.

In the MPA form, you will leave special instructions that depend on your will. These instructions may tell about:

  • Medical care in general
  • Preferred treatment
  • Live-sustaining procedures

And other things tied to your health care in critical conditions.

Every state in the US has different rules and laws regarding the MPA form. In some states, you will need to notarize the form. Others ask for a witness or two witnesses to make the form valid.

Pennsylvania Laws and Requirements

As stated in section § 5452(b.2) of the Pennsylvania state law, signing a form should be accompanied by two witnesses. You should be over 18 (or under this age but have the rights of an adult) and in sound mind.

You are to choose the future agent very carefully because one will make medical decisions for you. An agent can be any adult except for one from the medical staff of the hospital where you get treatment. But if at the same time one is your relative, then one can be.

Under Pennsylvania law, the signatures of you and other people involved should be in written form. After the signing process, an agent gets access to all your medical records for understanding what the right decision one must make on your behalf.

In Pennsylvania, you (as a declarant) may add two agents (principal and additional) in your health advance directive form. Do not forget to state the type of relationship that connects you with your agent (or agents).

The authors of the form recommend making a sufficient number of copies of your directive: give it to the agent, to your personal physician (if applicable), and to other people that might need it. From time to time, you may re-read your AD and create a new paper if your wish becomes different.

Filling Out the Form

We have prepared a detailed guide with all the required steps so you can easily complete the health care advance directive form in Pennsylvania. You may see this guide below.

1.   Download the Template

To start, you need to download the template of the health care advance directive form. To make it simple, use our form building software.

2.    Add Your Data

On the first line of the form, you, as a declarant, should place your full name and the name of your country.
Data adding section of Pennsylvania mpoa template

3.   Study the Information

Below you can see a text that contains the main information that concerns MDPA and transferring special rights to the agent.

4.   Fill out the Instructions for Your Agent

In this section, you should leave the instructions for your agent. They may include all the information about your will regarding your health conditions and medical care, including life-sustaining procedures, treatment, and other aspects. If you don’t agree with some points, you must cross them out.
Agent instructions part of a medical power of attorney document for Pennsylvania

5.     Choose Your Agent

Add the name of your agent and the type of relationship that ties you together. Below the name of this person, add his or her best phone numbers (work and home), one’s place of residence, and the mailing address.
Agent choosing section of Pennsylvania medical poa form

6.    Add Additional Agent

In Pennsylvania, you may appoint two additional agents in your form. Below the details of your initially chosen agent. Add the information about them. This is needed because sometimes your initial agent may also become unavailable or unable to act in accordance with your MDPA form.

Apart from the telephone numbers, mailing, and home addresses, you also need to state the type of relationship that connects you with your agents.
Additional agent adding section of a Pennsylvania medical power of attorney    

7.     Add Special Conditions

In the blank field of the next section, you may also add some instructions that can limit or increase the responsibilities of your agent.

8.     Specify the Information about the Donation and the Burial Process

In these sections, you can choose whether you want to donate your organs (and which particularly) and in what way to be buried (if you want, of course). You can also add the names of people who you want to learn about your last wishes.

9.      Insert the Information about Your Last Wishes

You are free to add some of your last wishes. For example, the name of the physician by whom you want to be treated or a particular medical place where you want to be in case of a serious illness.
Part for special conditions, information about donation and burial process, last wishes of a Pennsylvania mdpa

10.      Sign the MDPA Form

You, as a declarant, must check the information you have provided several times and then sign the document. If you are physically unable to do it, appoint a representative to sign the paper on your behalf. Ask the representative to insert details regarding their name, full address (information required in all sections in which the identity of a person must be specified).
SIgning part of Pennsylvania mdpa form

11.     Ask Two Witnesses to Sign

Two witnesses should sign, add the relevant data, birthdates, and their places of residence (with their cities and their states). Remember that none of your witnesses can act as your agent.
WItnesses signatures section of medical power of attorney for Pennsylvania

12.     Ask a Notary to Sign (If Needed)

The same rule applies to the MDPOA form notarization in Pennsylvania: it is optional. But if you want to notarize your MDPOA form, there is a section for a notary to sign. The notarization makes the document gain more legal force. A notary should verify the document by signing, adding a signing date, state and county (where the procedure took place), one’s full legal name, the date when commission expires, and putting a seal (if applicable).

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Published: Nov 20, 2020