To fill out the Act 52 medical consent form in Pennsylvania, you write in the name of the adult you’re authorizing, each child’s name and date of birth, and the categories of care that adult can approve, then sign the form in the simultaneous presence of two adult witnesses. The caregiver you’re naming cannot be one of those witnesses. Once signed, the original goes to the designated adult, who should keep it accessible whenever the child might need care.
The form is a limited delegation, not a custody transfer. You keep every parental right you had before signing, and you can revoke the authorization in writing at any time.
Confirm You’re Eligible to Sign
Three people can grant authority under Act 52: a biological or adoptive parent, a court-appointed legal guardian, or a legal custodian of the minor. The adult you name has to be either a relative or a family friend.
Two situations stop the form from working at all. If the child is currently in the custody of a county children and youth agency, a parent cannot use Act 52 to delegate consent. And if a court order in any jurisdiction restricts your ability to exercise the authority you’re trying to hand off, the form is invalid for that purpose.
The law also preserves a minor’s own consent rights. Where federal or state law gives the minor the independent right to consent to a particular treatment — Pennsylvania allows this for certain substance abuse and mental health services — an Act 52 form cannot transfer that decision to a caregiver.
Fill In the Three Required Pieces of Information
Pennsylvania law sets a minimum for what a valid authorization must contain. Work through the form in this order.
- The authorized person. Write the full name of the adult relative or family friend who will have the power to consent to the child’s treatment.
- The child. Write the name and date of birth of each minor covered by the form. If you’re authorizing care for more than one child, list each one individually.
- The scope of authority. Describe the categories of care the adult may approve — medical, surgical, dental, developmental, mental health, or other treatment — or describe a specific treatment being authorized.
Decide How Broad the Authority Should Be
The scope section is where you make the real decision. Broad authority across multiple categories suits a long absence, like a deployment or an extended stay with grandparents. Narrower authority makes sense when you’re authorizing something specific, like a dental appointment.
When you use the standardized categories the statute provides, cross out the ones that don’t apply. If the caregiver only needs to handle dental care, strike through medical, surgical, developmental, and mental health so the remaining authority is unambiguous on the page.
Sign With Two Witnesses at the Same Time
The signature rules are strict, and getting them wrong can invalidate the entire form. Sign in the presence of two witnesses, both at least 18 years old. All three signatures — yours and both witnesses’ — must be made contemporaneously, meaning at the same sitting.
The adult you’re naming as the authorized caregiver cannot serve as a witness. If you’re authorizing your mother to consent to your child’s care, she can’t also sign as one of your two witnesses. Line up two other adults for that role.
Notarization is not required under the Medical Consent Act. Some healthcare providers or schools may ask for it anyway. It doesn’t hurt to have the form notarized and it can reduce friction with facilities unfamiliar with Act 52, but a properly witnessed form is legally valid without it.
Add a Time Period If You Want One
The statute does not set an expiration date for the authorization. Writing one on the form is common practice. An open-ended authorization can create confusion later if your situation changes, so dating the form with a clear start and end — the length of a summer stay, the dates of a deployment, the duration of a hospital admission — keeps the scope obvious for anyone reading it.
Give the Signed Form to the Right People
Hand the original to the adult you’ve designated. That person should carry it or keep ready access to it whenever the child might need medical attention. In practice, most caregivers keep a copy in the child’s bag and leave another on file with the pediatrician or the school nurse.
Providers are not required to accept a photocopy in an emergency, so the original needs to be reachable. A copy usually satisfies a school, camp, or daycare that asks for proof of consent authority. Many parents also send a copy to their health insurance company so the caregiver can coordinate coverage without delays.
What the Form Doesn’t Do
Signing Act 52 does not terminate or limit any of your parental rights. You can revoke the authorization at any time by notifying the designated adult in writing.
The form also doesn’t need to cover true emergencies. Under Pennsylvania law, hospitals can treat a child in a life-threatening situation without a parental signature. Act 52 is most useful for routine and planned care where a provider would otherwise refuse to treat a minor without a parent present.
Don’t Confuse This With Act 31 of 2023
Searches for Act 52 sometimes surface information about Act 31 of 2023, which is a different law. Act 31 addresses patient consent for pelvic, rectal, or prostate examinations performed while a patient is under anesthesia, particularly in teaching hospital settings. It has nothing to do with delegating consent for a child’s care. If you’re working on authorizing a caregiver, Act 52 is the right law.