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West Virginia Health Care Power of Attorney Form

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
West Virginia Health Care Power of Attorney Form
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.
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 decision should be made
on my behalf during any period when I am unable to make such decisions.
West Virginia Health Care Power of Attorney Form
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