STATE OF WEST VIRGINIA
MEDICAL POWER OF ATTORNEY
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 repre
-
sentative)
This appointment shall extend to, but not be limited to, health care decisions relating to medical treatment, surgical treat
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ment, 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 diag-
nostic 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 feed-
ings, breathing machines, cardiopulmonary resuscitation, dialysis, funeral arrangements, autopsy and organ donation may be
placed here. My failure to provide special directives or limitations does not mean that I want or refuse certain treatments.)
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
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
(i) A combined medical power of attorney and living will may, but need not, be in the following form, and may include other
specific directions not inconsistent with other provisions of this article. Should any of the other specific directions be held to
be invalid, such invalidity does not affect other directions of the combined medical power of attorney and living will which
can be given effect without invalid direction and to this end the directions in the combined medical power of attorney and
living will are severable.
