Pennsylvania Medical Power of Attorney (POA) Form

The legal document entitled the Medical Power of Attorney is used to enable a specifically indicated person to take actions concerning the applicant’s health care and treatment on behalf of the applicant. The paper plays an important role in cases when the person is disabled to make such decisions on their own: due to a severe trauma, accident, their falling in a vegetative state, etc. What unites these cases is that a person cannot decide on their own future life and beyond.

Such a document can cease or continue health care treatment of the declarant, in the hands of a reliable agent or attorney who will act in favor of the declarant and according to their will described in the medical power of attorney form. It is strongly suggested that, for prevention of the situation when a person cannot act out of the disease or coma, the MDPOA form should be created beforehand. Such a practice is becoming widely spread throughout the United States these days.

The instructions usually included in the form are generally the following:

  • General health care issues
  • Medical treatment preferred
  • Life-prolonging operations and care
  • Any other instructions considered important by the applicant

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

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The Pennsylvania MDPOA Laws and Requirements

While in some states, the creation and validation of such a form may not require notarization or witnessing by a third party, other states’ laws may demand the conditions to be fulfilled. Pennsylvania is one of those states.

By the Pennsylvania General Assembly (Title 20, Chapter 54C, Sections from 5441 to 5447), the declarant is entitled to choose and assign up to two agents to take care of their healthcare-related business. You will need to insert the respective data on those two representatives, including their contact information and relationship type. These agents will get a legal right to decide on your life and health, so choose them wisely.

The declarant is also highly recommended to make some additional copies of the Pennsylvania Medical DPOA form for relevant local authorities that might require it. One (or two depending on the agents’ quantity) automatically goes to the agent, another goes to your physician (if applicable), and you can keep several others whom it may concern.

Pennsylvania Medical Power of Attorney Form Details

Document Name Pennsylvania Medical Power of Attorney Form
State Form Name Pennsylvania Durable Health Care Power of Attorney
State Laws Pennsylvania Consolidated Statutes, Title 20, Sections 5451 to 5465
Signing Requirements Two Witnesses
Who Can’t Be the Agent? Section 5455(b)
Who Can’t Be the Witness? Section 5452(c)
Avg. Time to Fill Out 8 minutes
# of Fillable Fields 21
Available Formats Adobe PDF

Filling Out the Form

Hereunder, you will find a comprehensive guide on filling out the Pennsylvania Medical DPOA Form. Follow the recommendations below to provide accurate information.

1. Download the Template

First of all, you need to obtain the relevant version of the form. You can either download it from the official website or use our form-building software to customize the form template you need and fill it out online.

2. Add Your Data

In the first line of the form, a declarant should input their full name and the name of the country of your residentship.

Data adding section of Pennsylvania mpoa template

3. Study the Information

Below you can see a text that contains the main information that concerns MDPOA and transferring special rights to the agent. These details are to be carefully read through in order to guarantee that in the end of the day, the wishes of the declarant are fulfilled to the utmost extent.

4. Fill out the Instructions for Your Agent

Here, you can designate the necessary instructions your assigned healthcare agent should act by when taking care of your business. Ensure to make the instructions as detailed as possible. This measure will help you avoid any misunderstandings or disputes in the future. The agent’s decision will concern your health directly, so take your time to fill this particular section 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, two more agents can be appointed. You should input the information concerning those to enable them to substitute the primal agent should he or she falls disabled to bear the prescribed responsibility. As such cases are no rarity, appointing additional agents is only essential.

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

This section concerns your assigned agent directly. If you want to imply any kind of limitation onto their activity on your behalf. you can insert those restrictions in the blank section below.

8. Specify Info on the Donation and 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).

seal of pennsylvania state
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Published: May 16, 2022