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Power of Attorney Authorization Form

After completing this form, hit the 'Continue' button and you will be prompted to print the form to be submitted. Sign in the designated area and then mail or fax it to the address listed on the printed form. If you do not have printing capabilities, please do not proceed.

Submission Requirements and Procedures

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
Do you (POA) have an active myGeisinger 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