Fillable Printable Medical Power of Attorney - West Virginia

Medical Power of Attorney - West Virginia

Rev. 04/2000

The Person I Want to Make Health Care Decisions

For Me When I Can’t Make Them for Myself

STATE OF WEST VIRGINIA

MEDICAL POWER OF ATTORNEY

Dated:_____________________________ , 20__ ____

I,____________________________________________________ ,

(Insert your name and address)

hereby appoint as my representative to act on my behalf to give, withhold or withdraw informed

consent to health care decisions in the event that I am not able to do so myself.

The person I choose as my representative is:

(Insert the name, address, area code and telephone number of the person you wish to designate

as your representative)

The person I choose as my successor representative is:

If my representative is unable, unwilling or disqualified to serve, then I appoint

(Insert the name, address, area code and telephone number of the person you wish to designate

as your successor representative)

This appointment shall extend to, but not be limited to, health care decisions relating to

medical treatment, surgical treatment, nursing care, medication, hospitalization, care and

treatment in a nursing home or other facility, and home health care. The representative

appointed by this document is specifically authorized to be granted access to my medical records

Rev. 04/2000

and other health information and to act on my behalf to consent to, refuse or withdraw any and

all medical treatment or diagnostic procedures, or autopsy if my representative determines that I,

if able to do so, would consent to, refuse or withdraw such treatment or procedures. Such

authority shall include, but not be limited to, decisions regarding the withholding or withdrawal

of life-prolonging interventions.

I appoint this representative because I believe this person understands my wishes and

values and will act to carry into effect the health care decisions that I would make if I were able

to do so, and because I also believe that this person will act in my best interest when my wishes

are unknown. It is my intent that my family, my physician and all legal authorities be bound by

the decisions that are made by the representative appointed by this document, and it is my intent

that these decisions should not be the subject of review by any health care provider or

administrative or judicial agency.

It is my intent that this document be legally binding and effective and that this document

be taken as a formal statement of my desire concerning the method by which any health care

decisions should be made on my behalf during any period when I am unable to make such

decisions.

In exercising the authority under this medical power of attorney, my representative shall

act consistently with my special directives or limitations as stated below.

I am giving the following SPECIAL DIRECTIVES OR LIMITATIONS ON THIS

POWER: (Comments about tube feedings, breathing machines, cardiopulmonary resuscitation

and dialysis may be placed here. My failure to provide special directives or limitations does not

mean that I want or refuse certain treatments.

Rev. 04/2000

THIS MEDICAL POWER OF ATTORNEY SHALL BECOME EFFECTIVE ONLY UPON MY

INCAPACITY TO GIVE, WITHHOLD OR WITHDRAW INFORMED CONSENT TO MY

OWN MEDICAL CARE.

_____________________________

Signature of the Principal

I did not sign the principal’s signature above. I am at least eighteen years of age and am

not related to the principal by blood or marriage. I am not entitled to any portion of the estate of

the principal or to the best of my knowledge under any will of the principal or codicil thereto, or

legally responsible for the costs of the principal’s medical or other care. I am not the principal’s

attending physician, nor am I the representative or successor representative of the principal.

Witness: DATE:

STATE OF

Rev. 04/2000

COUNTY OF

I, _______________________________, a Notary Public of said

County, do certify that_________________________________________, as principal, and

__________________________ and _________________________, as witnesses, whose names

are signed to the writing above bearing date on the ____________ day of _____________,

20_____, have this day acknowledged the same before me.

Given under my hand this __________ day of _____________, 20____.

My commission expires:__________________________________________.

__________________________________________

Notary Public