Form Fr-2090-Mwhc - Virginia Advance Medical Directive Page 6
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7If you wish to make provisions for mental health care patients, use the Alternate Form for Virginia Advance Medical Directive.
I, _______________________________________, willingly and voluntarily make known my wishes in the event that I am incapable
Printed Name of Individual Making This Advance Directive for Health Care (Declarant)
making an informed decision about my health care, as follows:
(YOU MAY INCLUDE ANY OR ALL OF THE PROVISIONS IN SECTIONS I AND II BELOW.)
SECTION I: APPOINTMENT AND POWERS OF MY AGENT
(CROSS THROUGH THIS SECTION I IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE HEALTH CARE DECISIONS FOR YOU.)
A. Appointment of My Agent
I hereby appoint ______________________________________________________________________________________________
Name of Primary Agent
E-mail Address
____________________________________________________________________________________________________________
Home Address
Telephone Number
as my agent to make health care decisions on my behalf as authorized in this document. If the primary agent named above is not
reasonably available or is unable to act as my agent, then I appoint as successor agent to serve in this capacity:
____________________________________________________________________________________________________________
Name of Successor Agent
E-mail Address
____________________________________________________________________________________________________________
Telephone Number
Home Address
I grant to my agent full authority to make health care decisions on my behalf as described below. My agent shall have this authority
whenever and for as log as I have been determined to be incapable of making an informed decision. In making health care decisions
on my behalf, I want my agent to follow my desires and preferences as stated in this document or as otherwise known to him or her. If
my agent cannot determine what health care choice I would have made on my own behalf, then I want my agent to make a choice for
me based upon what he or she believes to be in my best interests.
B. Powers of My Agent
(IF YOU APPOINT AN AGENT ABOVE, YOU MAY GIVE HIM/HER THE POWERS SUGGESTED BELOW. YOU MAY CROSS THROUGH ANY POWERS LISTED BELOW THAT YOU DO
NOT WANT TO GIVE YOUR AGENT AND ADD ANY ADDITIONAL POWERS YOU DO WANT TO GIVE YOUR AGENT.)
The powers of my agent shall include the following:
6.
1. To consent to or refuse or withdraw consent to any type
To authorize my participation in any health care study approved
by an institutional review board or research review committee
of health care, including, but not limited to, artificial
according to applicable federal or state law if the study offers
respiration (breathing machine), artificially administered
the prospect of direct therapeutic benefit to me.
nutrition (tube feeding) and hydration (IV fluids), and
cardiopulmonary resuscitation (CPR). This authorization
7.
To authorize my participation in any health care study approved
specifically includes the power to consent to dosages of
by an institutional review board or research review committee
pain-relieving medication in excess of recommended
according to applicable federal or state law that aims to increase
dosages in an amount sufficient to relieve pain. This
scientific understanding of any condition that I may have or
otherwise to promote human well-being, even though it offers
applies even if this medication carries the risk of
no prospect of direct benefit to me.
additional or of inadvertently hastening my death.
8.
To make decisions regarding visitation during any time that I am
2. To request, receive and review any oral or written
admitted to any health care facility, consistent with the
information regarding my physical or mental health,
following direction:
including but not limited to medical and hospital records,
____________________________________________________
and to consent to the disclosure of this information as
____________________________________________________
necessary to carry out my directions as stated in this
9.
To take any lawful actions that may be necessary to carry out
advance directive.
these decisions, including the granting of releases of liability to
3. To employ and discharge my health care providers.
medical providers.
4. To authorize my admission, transfer, or discharge to or
10.
To donate all or part of my body for transplantation, therapy,
from a hospital, hospice, nursing home, assisted living
research or education.
facility or other medical care facility.
ADDITIONAL POWERS, IF ANY: __________________________
________________________________________________________
5. To continue to serve as my agent if I object to the agent’s
________________________________________________________
authority after I have been determined to be incapable of
________________________________________________________
making an informed decision.
________________________________________________________
*CH0015*
Virginia Advance Directive for Health Care – Basic Form
FR-2090-MWHC 9/2010
Page 1 of 2
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