Pennsylvania Medical Power of Attorney Template
This document serves as a Medical Power of Attorney in accordance with Pennsylvania state laws. It allows you to designate an individual to make medical decisions on your behalf in the event that you become unable to do so.
Principal Information:
- Name: ________________________________
- Address: ______________________________
- City: _________________________________
- State: Pennsylvania
- Zip Code: ____________________________
- Date of Birth: _________________________
Agent Information:
- Name: ________________________________
- Address: ______________________________
- City: _________________________________
- State: ________________________________
- Zip Code: ____________________________
- Phone Number: ________________________
Designation of Health Care Agent:
I, the undersigned, hereby appoint the individual named above as my health care agent. This agent is authorized to make medical decisions on my behalf in accordance with my wishes.
Effective Date:
This Medical Power of Attorney becomes effective upon my incapacity, as determined by my attending physician.
Specific Instructions:
If there are any specific medical treatments or procedures that I do or do not wish to receive, please specify below:
_________________________________________________________
_________________________________________________________
Signatures:
By signing below, I affirm that I am of sound mind and am executing this Medical Power of Attorney voluntarily.
Principal's Signature: ___________________________
Date: ________________________________________
Witness Signature: ____________________________
Date: ________________________________________
Witness Signature: ____________________________
Date: ________________________________________
Notarization:
State of Pennsylvania
County of ____________________________
Subscribed and sworn to before me this _____ day of __________, 20__.
Notary Public: ____________________________
My Commission Expires: ___________________