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West Virginia Health Care Power of Attorney Form

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The West Virginia health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.

West Virginia Health Care Power of Attorney Form Page 2
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 feedings, 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 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
West Virginia Health Care Power of Attorney Form
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