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Fillable Printable Medical Power of Attorney - West Virginia

Fillable Printable Medical Power of Attorney - West Virginia

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:
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
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