Fillable Advance Medical Directive Form - Virginia State printable pdf download

VIRGINIA ADVANCE MEDICAL DIRECTIVE

I, ___________________________________________________, willfully and voluntarily make known my desire and do hereby declare:

Section 1. Appointment of Agent to Make Health Care Decisions

(Cross through this section if you do not want to appoint an agent to make health care decisions for you.)

I hereby appoint the following as my primary agent to make health care decisions on my behalf as authorized in this document:

Primary Agent

Telephone Number

Fax Number

Address

E-mail Address

If the above named primary agent is not reasonably available or is unable or unwilling to act as my agent, then I appoint the following as

successor agent to serve in that capacity:

Successor Agent

Telephone Number

Fax Number

Address

E-mail Address

I hereby grant to my agent, named above, full power and authority to make health care decisions on my behalf as described below whenever

I have been determined to be incapable of making an informed decision about providing, withholding or withdrawing medical treatment. The

phrase “incapable of making an informed decision” means unable to understand the nature, extent and probable consequences of a proposed

medical decision or unable to make a rational evaluation of the risks and benefits of a proposed medical decision as compared with the risks

and benefits of alternatives to that decision, or unable to communicate such understanding in any way. My agent’s authority hereunder is

effective as long as I am incapable of making an informed decision.

The determination that I am incapable of making an informed decision shall be made by my attending physician and a second physician or

licensed clinical psychologist after a personal examination of me and shall be certified in writing. Such certification shall be required before

treatment is withheld or withdrawn, and before, or as soon as reasonably practicable after, treatment is provided, and every 180 days thereafter

while the treatment continues.

In exercising the power to make health care decisions on my behalf, my agent shall follow my desires and preferences as stated in this document

or as otherwise known to my agent. My agent shall be guided by my medical diagnosis and prognosis and any information provided by my

physicians as to the intrusiveness, pain, risks and side effects associated with treatment or nontreatment. My agent shall not authorize a course

of treatment which he knows, or upon reasonable inquiry ought to know, is contrary to my religious beliefs or my basic values, whether

expressed orally or in writing. If my agent cannot determine what treatment choice I would have made on my own behalf, then my agent

shall make a choice for me based upon what he believes to be in my best interests. My agent shall not be liable for the costs of treatment that

he/she authorizes, based solely on that authorization.

The powers of my agent shall include the following:

(Cross through any powers below you do not want to give your agent.)

A. To consent to, or refuse or withdraw consent to, any type of medical care, treatment, surgical procedure, diagnostic procedure, medication

and the use of mechanical or other procedures that affect any bodily function, including but not limited to artificial respiration, artificially

administered nutrition and hydration, and cardiopulmonary resuscitation. This authorization specifically includes the power to consent to

the administration of dosages of pain-relieving medication in excess of recommended dosages in an amount sufficient to relieve pain, even if

such medication carries the risk of addiction or inadvertently hastens my death;

B. To request, receive and review any information (whether verbal, written, printed or electronically recorded) regarding my physical or

mental health, including but not limited to medical, hospital and other records; and to consent to or authorize the use and disclosure of such

information; and to otherwise serve as my personal representative for such purposes;

C. To employ and discharge my health care providers;

D. To authorize my admission to or discharge (including transfer to another facility) from any hospital, hospice, nursing home, assisted living

facility or other medical care facility for services other than those for treatment of mental illness requiring admission procedures provided in

Article 1 (§37.1-63 et seq.) of Chapter 2 of Title 37.1;

E. To make decisions about who may visit me, subject to physician orders and policies of any institution to which I am admitted;

F. To take any lawful actions necessary to carry out these decisions, including the granting of releases of liability to medical providers.

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Advance Medical Directive Form - Virginia State

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