Medical Power Of Attorney Form printable pdf download

Last Name/First/Middle__________________________________

Opt In

INITIAL box if you agree to have

Address________________________________________________

this advance directive submitted to the WV e-Directive

City/State/Zip __________________________________________

Date of Birth (mm/dd/yyyy) _______/_______/_________

Registry, and released to treating health care providers.

Last 4 SSN ___ ___ ___ ___ Gender M___ F___

Complete information to RIGHT.

REGISTRY FAX: 844-616-1415

STATE OF WEST VIRGINIA

MEDICAL POWER OF ATTORNEY

The Person I Want to Make Health Care Decisions

For Me When I Can’t Make Them for Myself

Dated:___________________________ , 20 ____

I, ____________________________________________________________________________ , hereby

(Insert your name and address)

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 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.

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Medical Power Of Attorney Form