Pennsylvania Medical Power of Attorney Form

The Pennsylvania medical power of attorney form is a document whereas a Principal will provide powers to an Agent to oversee their health care decisions in the event the Principal becomes unable to express or communicate their health care wishes on their own. The health care directive when completed will protect the rights, wishes and medical decisions of the Principal above all. Completion of this document will assist your family, friends and most importantly, your selected Agent, better understand the true choices of the Principal.

This document will not allow an Agent to access the Principal’s finances, or real property. Personal property only to the level of utilizing assistance to the Principal.

This document may be revoked at the discretion of the Principal. A revocation must be placed into writing and delivered to the Agent.

How to Write

Step 1 – Titled Sections – Using these Materials – Before the Principal may reasonably begin, they must read the all of the following sections:

  • Check to be sure that you have the materials for each state in which you may receive health care
  • Actions Steps
  • Introduction to Pennsylvania Advance Health Care Directive:
  • Directive
  • Durable Health Care Powers
  • Living Will
  • Signature Page
  • AND

Completing Your Pennsylvania Advance Health Care Directive:

  • How the Principal Can Make Their Health Care Directive Legal
  • Who to Appoint as a Health Care Agent
  • How to Add Personal Instructions to the Directive
  • What to do If the Principal Should Change Their Mind
  • Other Important Facts
  • AND

Pennsylvania Advance Health Care Directive :

  • Introductory Remarks on Health Care Decision Making (Extensive Section)
  • AND

What To Do After Completing the Health Care Directive:

  • Read the section thoroughly

Step 2 – Durable Health Care Powers Document

  • Enter the name of the Principal
  • Enter the name of the county of the Principal’s residence
  • Read the remainder of this section leading to the next instructions

Step 3 – Appointment of Agent – Complete the Following:

  • Enter the name of the health care Agent
  • Enter the Relationship of Agent to Principal
  • Provide the Agent’s full address
  • Home phone
  • Work Phone
  • Cell Phone
  • Email address
  • AND

In the event the original Agent feels they may no longer have the ability to act on behalf of the Principal, the Principal may choose to select Alternate Agents all to serve consecutively as follows:

  • Enter the name of the Alternatess health care Agents
  • Enter the Relationships of Agents to Principal
  • Provide the Agent’s full addresses
  • Home phones
  • Work Phones
  • Cell Phones
  • Email addresses

Step 4 – Guidance for Health Care Agent(s) (Optional)

  • No matter what the special instructions, limitations, restrictions, whatever the Principal would like to convey, please this information into these lines. This will help the Agent understand exactly what the Principal’s wishes are. If more space is required, be sure to use added sheets to continue.
  • Be certain to sign and date every added page

Step 5 – Living Will – The Principal must read all of the information with regard to an end of life scenario prior to completion of this section. Once the instructions have been read and the Principal would wish to receive any of the treatments simply place the words “I Do Want” on the line behind each:

  • Heart-lung resuscitation (CPR)
  • Mechanical ventilator (breathing machine)
  • Dialysis (kidney machine
  • Surgery
  • Chemotherapy
  • Radiation treatment
  • Antibiotics

If the Principal would like to have the following, initial the lines preceding the treatment:

  • Principal would like tube feeding
  • OR
  • Principal would not like tube feeding

Step 6 – Health Care Agent’s Use of Instructions – The Principal shall select how the Agent should use their powers by selecting:

  • Health care agent must follow these instructions
  • OR
  • These instructions are only guidance. The health care agent shall have the final say and may override any of the Principal’s instructions.
  • If there are any exceptions to be indicated, place the instructions into the lines provided.

Step 7 – Legal Protection –

  • The Principal must read the information with regard to the protection of the Agent

Step 8 – Organ Donations –

  • If the Principal would choose to or choose not to, participate in organ donation, read the three statements and initial only one
  • Should the Principal consents enter the Principal’s specific instructions with regard to how they would like to participate

Step 9 – Signatures -Enter the following:

  • Print the name of the Principal
  • Date the signature in dd/mm/yyyy format (this document shall revoke all previous health care powers documents)
  • The Principal must enter their full legal name as signature for these directives

Step 10 – Witnesses – Submit the following:

  • Each witness must provide their signatures
  • Date their signatures in mm/dd/yyyy format
  • Enter each witnesses printed names