West Virginia Medical Power of Attorney
This Medical Power of Attorney is made in accordance with the West Virginia Health Care Decisions Act. It grants authority to a designated person to make medical decisions on behalf of the signer, should they become unable to communicate their wishes about medical treatment.
Part 1: Designation of Health Care Surrogate
I, __________________________ [Your Full Name], born on __________________________ [Your Date of Birth], residing at __________________________ [Your Address], being of sound mind, hereby appoint the following person as my Health Care Surrogate:
Name of Surrogate: __________________________
Relationship to Me: __________________________
Address: __________________________
Phone Number: __________________________
In the event that my primary surrogate is unable, unwilling, or unavailable to act as my Health Care Surrogate, I hereby designate the following person as my alternate Health Care Surrogate:
Name of Alternate Surrogate: __________________________
Relationship to Me: __________________________
Address: __________________________
Phone Number: __________________________
Part 2: Authority of Health Care Surrogate
My Health Care Surrogate is authorized to make all types of health care decisions for me, including decisions about refusing or withdrawing life-prolonging interventions, when I am no longer capable of making these decisions myself. This authority is subject to any limitations that I may set forth below:
Limitations: _____________________________________________________
Part 3: Duration of Authority
This Medical Power of Attorney becomes effective immediately upon my incapacitation and remains in effect until my death, unless I revoke it earlier.
Part 4: Signature
Signed this ____ day of ______________, ______.
____________________________________
[Your Signature]
State of West Virginia, County of _____________________
Subscribed and sworn to before me this ____ day of _______________, ______.
_____________________________
Notary Public
My Commission Expires: ___________________
Witness Statement
I declare that the person who signed this document is personally known to me, that he/she signed or acknowledged this Medical Power of Attorney in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as agent by this document.
Name of Witness #1: __________________________
Signature of Witness #1: __________________________
Date: __________________________
Name of Witness #2: __________________________
Signature of Witness #2: __________________________
Date: __________________________