MAKE YOUR FREE Pennsylvania Medical Power of Attorney
What is a Pennsylvania Medical Power of Attorney?
The person granting permission is called the "principal," and the people or organizations gaining authority are known as the "agents." Suited for Pennsylvania residents, our Power of Attorney for health care is made for use in Philadelphia County, Allegheny County, Montgomery County, and in every other county or municipality in the state. All Pennsylvania Healthcare PoA forms from Rocket Lawyer can be modified to address your unique situation. This essential document will provide verification to healthcare facilities and other parties that your selected agent can make choices for you.
When to use a Pennsylvania Medical Power of Attorney:
- You have concerns about your health and want to be prepared for worst-case scenarios.
- You want a certain person you trust to take over your medical decisions if you become unable to do so yourself.
Sample Pennsylvania Medical Power of Attorney
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DURABLE POWER OF ATTORNEY FOR HEALTH CARE
APPOINTMENT OF HEALTH CARE AGENT
I, , of , PA, appoint
| Health Care Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
as my Health Care Agent to make health care and personal decisions for me.
Effective immediately and continuously until my death or revocation by a writing signed by me or someone authorized to make health care treatment decisions for me, I authorize all health care providers or other covered entities to disclose to my health care agent, upon my agent's request, any information, oral or written, regarding my physical or mental health, including, but not limited to, medical and hospital records and what is otherwise private, privileged, protected or personal health information, such as health information as defined and described in the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat. 1936), the regulations promulgated thereunder and any other State or local laws and rules. Information disclosed by a health care provider or other covered entity may be redisclosed and may no longer be subject to the privacy rules provided by 45 C.F.R. Pt. 164.
The remainder of this document will take effect when and only when I lack the ability to understand, make or communicate a choice regarding a health or personal care decision as verified by my attending physician. My health care agent may not delegate the authority to make decisions.
To authorize, withhold or withdraw medical care and surgical procedures.
To authorize, withhold or withdraw nutrition (food) or hydration (water) medically supplied by tube through my nose, stomach, intestines, arteries or veins.
To authorize my admission to or discharge from a medical, nursing, residential or similar facility and to make agreements for my care and health insurance for my care, including hospice and/or palliative care.
To hire and fire medical, social service and other support personnel responsible for my care.
To take any legal action necessary to do what I have directed.
To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order, including an out-of-hospital DNR order, and sign any required documents and consents.
IF YOU DO NOT NAME A HEALTH CARE AGENT, HEALTH CARE PROVIDERS WILL ASK YOUR FAMILY OR AN ADULT WHO KNOWS YOUR PREFERENCES AND VALUES FOR HELP IN DETERMINING YOUR WISHES FOR TREATMENT. NOTE THAT YOU MAY NOT APPOINT YOUR DOCTOR OR OTHER HEALTH CARE PROVIDER AS YOUR HEALTH CARE AGENT UNLESS RELATED TO YOU BY BLOOD, MARRIAGE OR ADOPTION.
SECOND ALTERNATE HEALTH CARE AGENT
| Health Care Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
GUIDANCE AND LIMITATIONS FOR HEALTH CARE AGENT
When making health care decisions for me, my health care agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in this or any other document, my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then my health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.
Limitations on the decision-making authority of my Health Care Agent:
PRINCIPAL'S INTENTION REGARDING THE INITIATION, CONTINUATION, WITHHOLDING OR WITHDRAWAL OF LIFE-SUSTAINING TREATMENT:
PRINCIPAL'S INTENTION REGARDING TUBE FEEDING OR ANY OTHER ARTIFICIAL OR INVASIVE FORM OF NUTRITION OR HYDRATION:
NO, would not like nutrition or hydration to be medically supplied.
LEGAL PROTECTION
Pennsylvania law protects my health care agent and health care providers from any legal liability for their good faith actions in following my wishes as expressed in this form or in complying with my health care agent's direction. On behalf of myself, my executors and heirs, I further hold my health care agent and my health care providers harmless and indemnify them against any claim for their good faith actions in recognizing my health care agent's authority or in following my treatment instructions.
I have read and understand the contents of this document and the effect of this grant of powers to my Health Care Agent. I am emotionally and mentally competent to make this declaration.
Signed on _____ day of _______________, _____.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
Two witnesses at least 18 years of age are required by Pennsylvania law and should witness your signature in each other's presence.
STATEMENT OF WITNESSES
I declare that the person who signed or acknowledged this document () has identified himself or herself to me, that signed or acknowledged this document in my presence, that appears to be of sound mind, and under no duress, fraud or undue influence. I am not the person appointed as Health Care Agent or Alternate Health Care Agent by this document, nor am I the operator of a community care facility, or an employee of an operator of a health care facility.
I further declare that I am not related to by blood, marriage, or adoption, and to the best of my knowledge, I am not a creditor of or entitled to any part of the estate of under a will now existing or by operation of law. Each of us is at least 18 years of age.
| Witness Signature: | ________________________________________ |
| Witness Signature: | _________________________________________ |
Pennsylvania Medical Power of Attorney FAQs
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Can I get a Pennsylvania Medical Power of Attorney template online for free?
It's fast and easy to give or receive the authority you need using a free Pennsylvania Medical Power of Attorney template from Rocket Lawyer:
- Make your document - Answer a few questions and we will do the rest
- Send and share - Go over it with your agent(s) or get legal advice
- Sign it and make it legal - Required or not, witnesses/notarization are recommended
This route is, in many cases, much less expensive than meeting and hiring your average attorney. If necessary, you may start this Medical PoA on behalf of a family member, and then have that person sign when ready. Keep in mind that for a Power of Attorney to be considered valid, the principal must be a mentally competent adult when they sign. If the principal has already been declared legally incompetent, a court-appointed conservatorship may be necessary. When facing such a situation, it is important for you to speak with a lawyer .
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Who should have a Power of Attorney for healthcare in Pennsylvania?
Every person over 18 years old ought to have a Medical Power of Attorney. While it may be painful to think about, there may come a day when you aren't able to make medical decisions on your own. Common circumstances in which you may find PoA forms to be useful include:
- You intend to live in a care facility
- You've been given a terminal diagnosis
- You are aging or have declining health
- You will be in the hospital for a medical procedure
Whether your Pennsylvania Medical Power of Attorney is being generated as part of a forward-looking plan or created as a result of an unexpected emergency, witnesses and/or notarization can often help to protect your agent if their authority is doubted by a third party.
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Are a Pennsylvania Healthcare Proxy and a Pennsylvania Medical Power of Attorney the same thing?
In researching the topics of estate planning and/or elder care, you or a loved one may see "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" being used interchangeably. In short, they are the same. That said, it's certainly possible to get power of attorney over affairs that aren't related to medical care, in which case, "proxy" is not commonly used.
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Should I hire an attorney for my Pennsylvania Medical PoA?
Pennsylvania Medical PoA forms are usually simple, but you or your agent(s) could still have legal questions. The answer will vary depending on whom you contact, but sometimes an attorney may not even agree to review a document that they didn't draft. A more favorable approach might be through Rocket Lawyer attorney services. If you sign up for a Premium membership, you will be able to request feedback from an Rocket Lawyer network attorney with relevant experience or ask other questions about your Medical Power of Attorney. As always, we'll be here to support you.
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What might I typically have to pay for an attorney to help me get a Power of Attorney form for health care in Pennsylvania?
The fees associated with finding and hiring a traditional attorney to write a Medical Power of Attorney might be between $200 and $500, based on your location. When using Rocket Lawyer, you are not just filling out a Power of Attorney template. If you ever require support from a lawyer, your Premium membership provides up to a 40% discount when you hire an Rocket Lawyer network attorney.
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What should I do after I create a Pennsylvania Medical Power of Attorney?
After creating the document with Rocket Lawyer, you will be able to view it anytime and anywhere. You should feel free to interact with your PoA in any or all of the following ways: editing it, printing it out, or signing it. Each Power of Attorney has a checklist of next steps you can take to finalize the document. Your agent(s) and care providers should get a copy of your fully executed document.
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Does a Medical Power of Attorney need to be notarized, witnessed, and/or recorded in Pennsylvania?
The rules and restrictions are different by state; however, in Pennsylvania, your document must be signed by two witnesses. Where applicable, the witnesses to a Healthcare PoA must not include the person who signed the document on your behalf. As a basic principle, witnesses must be 18 years old or older, and none of them should also be designated as your agent.
See Pennsylvania Medical/Healthcare Power of Attorney law: Title 20, Chapter 54, Subchapter C
