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Free Pennsylvania Medical Power of Attorney Form

A Pennsylvania medical power of attorney names the agent who makes health care decisions when you cannot. Our step-by-step questionnaire follows the state's Act 169 sample form and its two-witness rule.

  • Download as PDF and Word
  • E-sign included

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2

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3

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What Is a Medical Power of Attorney in Pennsylvania?

Pennsylvania calls this a health care power of attorney, governed by Chapter 54 of Title 20 of the Pennsylvania Consolidated Statutes, as enacted by Act 169 of 2006. It can stand alone or be combined with a living will.

Pennsylvania Signing Rules

Pennsylvania’s sample form and 20 Pa.C.S. § 5452 set out how to sign.

Two Adult Witnesses

Pennsylvania law requires your Pennsylvania medical power of attorney to have two witnesses at least 18 years old. The sample form says they should witness your signature in each other’s presence.

The Person Signing for You Cannot Witness

If someone signs your Pennsylvania medical power of attorney on your behalf and at your direction, that person may not also be a witness.

Providers Cannot Sign for You

A health care provider, or its agent, that provides health care services to you may not sign the document on your behalf.

Does a Pennsylvania Medical Power of Attorney Need a Notary?

No, Pennsylvania does not require notarization for a health care power of attorney. The state’s sample form says so directly.

The same form adds that a document both witnessed and notarized is more likely to be honored under the laws of some other states. If you spend time outside Pennsylvania, notarizing is a simple extra step.

Pick Witnesses With No Stake

Pennsylvania’s sample form suggests that witnesses preferably not be your heirs, your creditors, or employed by any of your health care providers. The law does not require this, but choosing independent witnesses follows the form’s advice.

How to Sign Your Pennsylvania Medical Power of Attorney

Prepare your Pennsylvania medical power of attorney form with these steps:

  1. Name your health care agent and a successor agent.
  2. Add any treatment instructions, including organ donation wishes.
  3. Choose two adult witnesses, ideally with no stake in your estate.
  4. Sign while both witnesses are present, then have them sign.
  5. Add a notary acknowledgment if you want extra portability.
  6. Give copies to your agent and your doctors.

What to Include in Your Pennsylvania Form

Pennsylvania’s Act 169 sample form combines a health care power of attorney with health care treatment instructions. A complete Pennsylvania document usually includes:

  • Your health care agent and a successor
  • Treatment instructions for end-of-life care
  • Your choice about organ and tissue donation
  • Signatures of you and two adult witnesses, with an optional notary block

When you sign the sample form, you also revoke all your previous health care powers of attorney and health care treatment instructions. Gather up older copies so no one relies on them by mistake.

Talk with your agent before you sign. Explaining your values ahead of time makes it easier for them to follow your wishes when a hard decision comes up.