Surrogate Selection Checklist Form

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Last Name/First/Middle__________________________________
Opt In
INITIAL box if surrogate agrees to
Address________________________________________________
have this form 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: 304-293-7442
Checklist for Surrogate Selection
(In accordance with the West Virginia Health Care Decisions Act)
W.V. Code - § 16-30-8
Patient’s Name:________________________________
A. DETERMINATION IF HEALTH CARE DECISIONS ACT APPLICABLE
1.
Is this patient an adult (over the age of 18), an emancipated minor, or a mature minor? Yes ____ No ____
If no, stop now. The Health Care Decisions Act of 2000 does not apply to selecting a surrogate to make
decisions for children. An emancipated minor is a person over the age of 16 who has been declared
emancipated by a judge or who is over the age of 16 and married. A mature minor is a person less than 18
years of age who has been determined by a qualified physician, a qualified psychologist, or an advanced nurse
practitioner to have the capacity to make health care decisions.
Has the patient been declared “incapacitated”? Yes ____ No ____
2.
If no, stop now. Make the decision with the patient. (“Incapacity” means the inability because of physical or
mental impairment to appreciate the nature and implications of a health care decision, to make an informed
choice regarding the alternatives presented, and to communicate that choice in an unambiguous manner.)
3.
The determination of incapacity must be made by the attending physician, a qualified physician, a qualified
psychologist, or an advanced nurse practitioner.
Name of the physician _____________________________________ Date ________ Time ________
a. Cause: ________________________________________________________________________________
b. Nature: _______________________________________________________________________________
c. Duration: ______________________________________________________________________________
i. Was the determination made regardless of age and disability? Yes ____ No ____
If no, the patient must be reevaluated without a presumption of incapacity.
ii. Does this patient have a court-appointed guardian with the authority to make health care decisions
or Medical Power of Attorney (MPA)?
Yes ____ No ___
(Note that one physician, one licensed psychologist, or one advanced nurse practitioner who has
personally examined the patient must document incapacity for the Medical Power of Attorney to be in
effect.) If yes, the guardian or MPA representative is authorized to make health care decisions for the
patient.
Is the guardian or representative named in the MPA available and willing to serve? Yes ____ No ____
If yes, stop and follow the directives of the guardian or representative in accordance with the patient’s
wishes, or if unknown, best interest. If the patient has a guardian or MPA representative, selection of
a surrogate is not authorized by state law. If neither a guardian nor a MPA representative is available
and willing to serve, proceed with surrogate selection.

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