In witness hereof, I have signed my name to this medical consent authorization, on this ____ day of. A medical power of attorney form in Pennsylvania designates an individual to make healthcare decisions for someone else when they're incapacitated.The physician certification form is a state form that must accompany the application for Medicaid waiver services. It is also known as the MA 570 form. An advance health care directive is a written set of instructions expressing your wishes for medical treatment. By signing this form, I understand that I am authorizing Penn Medicine to release information as described above. Complete and cut out the cards below. 1 Information that is to be disclosed must be identified in the section. For example: medical records, DHS case records, etc. The Department will issue a medical marijuana patient authorization letter to a minor patient instead of issuing an identification card to the minor patient.