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Power of Attorney Authorization Form

After completing this form, hit the 'Continue' button. Then click the 'Click Here to Print Form' button. Sign the forms and then mail, email, or fax the documentation. If you don't have access to a printer call 570-271-7292 to have the forms mailed to you.

Submission Requirements and Procedures
Asterisk (*) denotes a required field

Patient Information

Patient Address
 

Power of Attorney (POA)

Please indicate your relationship to the patient by selecting one of the following:*
Son Daughter Spouse Other
Poa Address Same as Patient?
Do you (POA) have an active MyChart account? Yes No Unsure
Is this request to access the patient's MyChart Bedside information while the patient is admitted to the hospital?* Yes No