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West Virginia Medical Power of Attorney Form

A resident of West Virginia must fulfill this form if s/he elects another person as her/him representative in medical matters. Mostly, this form is used by individuals expecting the loss of their cognitive functions later in life.Download

Extracted Text for Proper Search

STATE OF WEST VIRGINIA
COMBINED MEDICAL POWER OF ATTORNEY AND LIVING WILL	
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).
If my representative is unable, unwilling or disqualified to serve, then I appoint as my successor representative:
(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
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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	
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ings, breathing machines, cardiopulmonary resuscitation, dialysis, mental health treatment, 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).
1. If I am very sick and not able to communicate my wishes for myself and I am certified by one physician who has person	
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ally examined me, to have a terminal condition or to be in a persistent vegetative state (I am unconscious and am neither 
aware  of  my  environment  nor  able  to  interact  with  others,)  I  direct  that  life-  prolonging  medical  intervention  that  would 
serve solely to prolong the dying process or maintain me in a persistent vegetative state be withheld or withdrawn. I want to 
be allowed to die naturally and only be given medications or other medical procedures necessary to keep me comfortable. I 	
want to receive as much medication as is necessary to alleviate my pain.
2. Other directives
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 writ	-	
ing 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:   
Signature of Notary Public
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