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Medical Power of Attorney Form - Wyoming

MEDICALPOWEROFATTORNEY
STATEOFWYOMING)
)ss.
COUNTYOF__________)
KnowAllMenByThesePresentsthatI,___________________,residingat
_________________,_____________,Wyoming,________herebymake,constitute,
andappoint,____________________mytrueandlawfulattorneyinfactforuseandin
myname,placeandstead,andonourbehalfandformyuseandbenefitasfollows:
ToobtainmedicalcareforwhateverreasonasrequiredifIamunabletodoso
formyselfforwhateverreason.____________________hastheauthoritytocontract
withanyphysician,hospital,orothertypeofhealthfacilitywhichisnecessaryto
providefortheadequatecareofmyself,___________________.
Theabovenamedindividualshallhavetheauthoritytocompleteandsignany
requireddocumentation,authorizations,orreleasenecessarytoobtaintherequisite
medicalcareandtootherwiseexerciseorperformanyact,power,duty,right,or
obligationwhatsoeverthatIwouldhaveormayberequiredtoexerciseorperformto
obtainthenecessarymedicalcareformyselfifIamunabletodosoforanyreason.
Theabove-namedindividualshallhavethepowerandauthoritytodo,take,and
performallandeveryactorthingwhatsoeverrequisite,proper,ornecessarytobedone
intheexerciseofanyoftherightsandpowershereingrantedasfullytoallextentand
purposeasImightorcoulddoifIwerepersonallycapablewithfullpowerof
substitutionorrevocationherebyratifyingandconfirmingallthatsaidattorneyinfact
shalllawfullydoorcausetobedonebyvirtueofthisPowerofAttorneyandtherights
andpowershereingranted.ThismedicalPowerofAttorneyintheenumerationofsaid
specificitems,rights,acts,andpowershereinisnotintendedto,nordoesitlimitor
restrict,andisnottobeconstruedorinterpretedaslimitingorrestrictingthemedical
powershereingrantedtosaidattorneyinfact.
Therights,powers,andauthoritiesofthesaidattorneyinfacthereingranted
shallcommenceonthe_______dayof_______,20___,andsuchrights,powers,and
authoritiesshallremaininfullforceandeffectuntilrevokedinwriting.Bysigning
thisMedicalPowerofAttorneyIamherebyrevokingallpreviousMedicalPowerof
Attorneysinwhateverformtheymaybeandwherevertheymaybekept.
DATEDthis_____________dayof___________________________,20___.
_________________________________
___________________
STATEOFWYOMING)
)ss.
COUNTYOF___________ )
SUBSCRIBEDANDSWORNtomethis_______dayof_____________,20___,
by___________________.
WITNESSmyhandandofficialseal.
_______________________________
NotaryPublic
Mycommissionexpires:
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