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Wyoming Medical Health Care Power of Attorney Form

In Wyoming, a resident must fulfill this form if s/he elects another person as her/his representative in medical matters. Use of this form is endorsed to individuals expecting the loss of their decision-making function later in life.Download

Extracted Text for Proper Search

6 	
WYOMING ADVANCE HEALTH CARE DIRECTIVE – PAGE  1 OF  8 
 
 
I,            	
(print name), make   	
 
this Advance Health Care Directive on       	(print date).  	
 
PART 1: POWER OF ATTORNEY FOR HEALTH CARE  
 
(1) DESIGNATION OF AGENT :  I designate the following individual as 
my agent to make health care decisions for me:  
  ___________________________________________________________  
(name of individual you choose as agent)  
 
___________________________________________________________  
(address, city, state, zip code)  
 
___________________________________________________________  
(home phone and work phone) 
 
OPTIONAL : If I revoke my  agent’s authority or if my agent is not willing, 
able or reasonably available to make a health care decision for me, I 
designate as my first alternate agent:  
  ___________________________________________________________  
(name of individual you choose as ag ent) 
 
___________________________________________________________  
(address, city, state, zip code)  
 
___________________________________________________________  
(home phone and work phone) 
 
OPTIONAL : If I revoke the authority of my agent and first alternate  
agent or if neither is willing, able or reasonably available to make a health 
care decision for me, I designate as my second alternate agent:  
  ___________________________________________________________  
(name of individual you choose as agent)  
 
___________________________________________________________  
(address, city, state, zip code)  
 
___________________________________________________________  
(home phone and work phone)	
 
 
 
PRINT YOUR NAME 
AND THE DATE  
 
 
PART 1  
 
 
 
 
PRINT NAME,  
ADDRESS AND  
TELEPHONE  
NUMBERS OF  
YOUR PRIMARY  
AGENT   
 
 
 
 
 
 
 
 
 
PRINT NAME,  
ADDRESS AND  
TELEPHONE  
NUMBERS OF  
YOUR FIRST 
ALTERNATE AGENT  
 
 
 
 
 
 
 
 
 
PRINT NAME,  
ADDRESS AND  
TELEPHONE  
NUMBERS OF  
YOUR SECOND 
ALTERNATE AGENT  
 
© 2005 National 
Hospice and 
Palliative Care 
Organization . 
201 2 Revised .

7 	
WYOMING ADVANCE HEALTH CARE DIRECTIVE – PAGE  2 OF  8 
 
 
(2)  AGENT’S AUTHORITY :  My agent is authorized to make all health 
care decisions for me, including decisions to provide, withhold or 
withdraw artificial nutrition and hydration and all other forms of health 
care to keep me alive, except as I state here:  
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________ ________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
_______________________________ ____________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________  
(	
Add additional sheets if needed.) 	
 
(3) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s 
authority becomes effective when my  primary physician or supervising 
health care provider determines that I lack the capacity to make my own 
health care d ecisions unless I initial the following bo x.  If I initial this box 
[        ], my agent’s authority to make health care decisions for me takes 
effect immediately.  
 
(4) AGENT’S OBLIGATION : My agent shall make health care decisions 
for me in accordance with  this Power of Attorney for Health Care, any 
instructions I give in Part 2 of this form, and my other wishes to the 
extent known to my agent.  To the extent my wishes are unknown, my 
agent shall make health care decisions for me in accordance with what 
my a gent determines to be in my best interest.  In determining my best 
interest, my agent shall consider my personal values to the extent known 
to my agent.  	
 
 
 
 
 
 
 
ADD PERSONAL 
INSTRUCTIONS 
ONLY IF  YOU WANT 
TO LIMIT  THE 
POWER OF YOUR 
AGENT  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
INITIAL THE BOX 
ONLY IF YOU WISH 
YOUR AGENT’S 
AUTHORITY TO 
BECOME EFFECTIVE 
IMMEDIATELY  
 
CROSS OUT AND 
INITIAL ANY 
STATEMENTS IN 
PARAGRAPHS 3  OR 
4  THAT DO NOT 
REFL ECT YOUR 
WISHES.   
 
© 2005 National 
Hospice and 
Palliative Care 
Organization . 
2012 Revised .

8 	
WYOMING ADVANCE HEALTH CARE DIRECTIVE – PAGE  3 OF  8 
 
(5) NOMINATION OF GUARDIAN : If a guardian of my person needs 
to be appointed for me by a court, (	
please initial one of the following):	 
 
[       ] I nominate the agent(s) whom I named in this form in  the order 
designated to act as guardian.  
 
[      ] I nominate the following to be guardian in the order  designated: 
 
___________________________________________________________  
(name, address and phone of individual designated as guardian)  	
 	
___________________________________________________________  
(name, address and phone of alternate designated as guardia n) 	
 	
___________________________________________________________  
(name, address and phone of second alternate designated as guardian)  
 
[      ] I do not nominate anyone to be guardian.  
 	
 
 
 
 
 
 
INITIAL ONLY ONE  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization . 
2012 Revised .

9 	
WYOMING ADVANCE HEALTH CARE DIRECTIVE – PAGE  4 OF  8 
  PART 2: INSTRUC TIONS FOR HEALTH CARE  
 
 
(6) END -OF -LIFE DECISIONS :	
 I direct that my health care providers 
and others involved in my health care provide, withhold or withdraw 
treatment in accordance with the choice I have initialed below:  
 
[      ] (a)  Choice Not to  Prolon g Life –  I do not want my life to be 
prolonged if:  
 
  (i) I have an incurable and irreversible condition that will result in   
my death within a relatively short time,  
 
  (ii) I become unconscious and, to a reasonable degree of medical   
certainty, I will not  regain consciousness, or   
 
  (iii) the likely risks and burdens of treatment would outweigh the   
expected benefits.  
OR 
 
[      ] (b)  Choice to Prolong Life  –  I want my life to be prolonged as 
long as possible within the limits of generally accepted health c are 
standards  
 
(7) ARTIFICIAL NUTRITION AND HYDRATION : Artificial nutrition 
and hydration must be provided, withheld or withdrawn in accordance 
with the choice I have made in paragraph (6) unless I initial the following 
box.  If I initial this box [      ] , artificial hydration must be provided 
regardless of my condition and regardless of the choice I have made in 
paragraph (6).  
 
 
 	
 
 
PART 2  
 
STRIKE THROUGH  
AND INITIAL ANY 
LANGUAGE THAT 
DOES NOT REFLECT 
YOUR WISHES  
 
 
INITIAL ONLY ONE  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
INITIAL THE BOX 
ONLY IF YOU WANT 
ARTIFICIAL 
NUTRITION AND 
HYDRATION 
REGARDLESS OF 
YOUR MEDICAL 
CONDITION  
 
 
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Ca re 
Organization . 
2012 Revised .

10	 	
WYOMING ADVANCE HEALTH CARE DIRECTIVE – PAGE  5 OF  8 
 
 
(8) RELIEF FROM PAIN : Except as I state in the following space, I 
dire ct that treatment for alleviation of pain or discomfort be provided at all 
times:  
____________________________________________________________
____________________________________________________________  
 
 
(9) OTHER WISHES :  (	
If you do not agree with any of  the optional 
choices above and wish to write your own, or if you wish to add to the  instructions you have given above, you may do so here.)	
   I direct that:  
____________________________________________________________
_______________________________________ _____________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
___________ _________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________  
(	
Add additional sheets if need ed.) 	
 
 
 
 
 
 
 
 
 
 
 
 
ADD OTHER 
INSTRUCTIONS, IF 
ANY, REGARDING 
YOUR ADVANCE 
CARE PLANS 
 
THESE 
INSTRUCTIONS CAN 
FURTHER ADDRESS 
YOUR HEALTH CARE 
PLANS, SUCH AS 
YOUR WISHES 
REGARDING 
HOSPICE 
TREATMENT, BUT 
CAN ALSO ADDRESS 
OTHER ADVA NCE 
PLANNING ISSUES, 
SUCH AS YOUR 
BURIAL WISHES  
 
ATTACH 
ADDITIONAL PAGES 
IF NEEDED  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization . 
2012 Revised .

11	 	
WYOMING ADVANCE HEALTH CARE DIRECTIVE – PAGE  6 OF  8 
  PART 3: DONATION OF ORGANS AT DEATH (OPTIONAL)  
 
(10) UPON MY DEATH  (	
initial applicable box):	 
 
[      ] (a) I give my body; or   
 
[      ] (b) I give any needed organs, tissues or parts; or  
 
[       ] (c) I give the following organs, tissues or parts only:  
  ______________________________________________________  
  ______________________________________________________  
  ______________________________________________________  
 
(d) My gift is for the follo wing purpose (	
strike and initial  any of the 
following you do NOT want)	
 
 
  (i) Any purpose authorized by law;  
  (ii) Transplantation;  
  (iii) Therapy;  
  (iv) Research;  
  (v) Medical education.  	
 
PART 3 
 
IF YOU DO NOT 
WISH TO DONATE 
ORGANS, DO NOT 
COMPLETE PART 3  
 
OTHERWISE 
INI TIAL THE 
STATEMENTS THAT 
REFLECT YOUR 
INTENT AND CROSS 
OUT ANY 
STATEMENTS THAT 
DO NOT REFLECT 
YOUR INTENT  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization . 
2012 Revised .

12	 	
WYOMING ADVANCE HEALTH CARE DIRECTIVE – PAGE 7 OF 8  
  PART 4: PRIMA RY PHYSICIAN (OPTIONAL)   
 
(11) PRIMARY PHYSICIAN: I designate the following physician as my 
primary physician:  
 
 
____________________________________________________________  
(name, address and phone of primary physician)  
 
 
If the physician I have designate d above is not willing, able or reasonably 
available to act as my primary physician, I designate the following as my 
primary physician:  
 
____________________________________________________________  
(name, address and phone of alternate primary physician)  
 
 
************************************************************  
 
 
(12) EFFECT OF COPY : A copy of this form has the same effect as the 
original.   
 
 
 
 	 
PART 4  
 
IF YOU DO NOT 
WANT TO NAME A 
PRIMARY 
PHYSICIAN, DO NOT 
COMPLETE PART 4.  
 
OTHERWISE, PRINT 
THE NAME, 
ADDRESS AND 
TELEPHONE 
NUMBER OF YOUR 
PRIMARY 
PHYSICIAN AND 
ANY ALTERNATE 
PRIMARY 
PHYSICIAN.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
© 2005 National 
Hospice and 
Palliative Care 
Organization . 
2012 Revise d.

13	 	
WYOMING ADVANCE HEALTH CARE DIRECTIVE – PAGE 8 OF 8 
 	
PART 5.  EXECUTION  
 	
Sign:         	 Date:      	 	
Print Name :            	 	
Residence Address:          _______	 	
                                 ______________________________________	 	
WITNESS STATEMENT  
I declare under penalty of perjury under the laws of Wyoming that the person 
who signed or acknowledged this document is p ersonally known to me to be the 
principal, that the principal signed or acknowledged this document in my 
presence, that the principal appears to be of sound mind and under no duress, 
fraud or undue influence, that I am not the person appointed as agent by  this 
document, and that I am not a treating health care provider, an employee of a 
treating health care provider, the operator of a community care facility, an 
employee of an operator of a community care facility, the operator of a 
residential care facilit y or an employee of an operator of a residential care 
facility.  
WITNESSES  	
Witness #1	: 	
Sign:         	 Date:      	 	
Print Name:            	 	
Residence Address:           	 	
Witness #2	:  	
Sign:         	 Date:      	 	
Print Name:            	 	
Residence Address:           	 	
—OR — 
SIGNAT URE OF NOTARY PUBLIC IN LIEU OF WITNESSES  
The State of Wyoming  
County of _____________  
Subscribed, sworn to, and acknowledged before me by  	
        	, the principal, this   	
____ day of _______________, 20___.  
(SEAL)   	 	
Courtesy of Caring Connections  
1731 King  St., Suite 100, Alexandria, VA  22314  
www.caringinfo.org, 800/658- 8898	
 
 
PART 5 
 
 
SIGN AND DATE 
AND PRINT YOUR 
NAME AND 
ADDRESS  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HAVE YOUR 
WITNESSES SIGN 
AND DATE THE 
DOCUMENT AND 
PRINT THEIR NAME 
AND ADDRESS HERE  
 
 
 
 
— OR — 
 
 
HAVE  A NOTARY 
PUBLIC FILL OUT 
THIS SECTION  
 
 
 
 
 
 
© 2005 National 
Hospice and 
P alliative Care 
Organization . 
2012 Revised .

14	 	
You Have Filled Out Your Health Care Directive, Now What? 
 
1.  You r 	
Wyoming Advance Health Care Directive	 is an important legal document.  Keep 
the original signed document in a secure but accessible place.  Do not put the original 
document in a safe deposit box or any other security box that would keep others from 
having access to it.  
 
2.  Give photocopies of the signed original to your agent and alternate agent, doctor(s), 
family, close frie nds, clergy, and anyone else who might become involved in your  health 
care . If you enter a nursing home or hospital, have photocopies of your document 
placed in your medical records.  
 
3.  Be sure to talk to your agent(s), doctor(s), clergy, family, and friends  about your wishes 
concerning medical treatment. Discuss your wishes with them often, particularly if your 
medical condition changes.  
 
4.  You may also want to save a copy of your form in an online personal health records 
application, program, or service that  allows you to share your medical documents with 
your physicians, family, and others who you want to take an active role in your advance 
care planning.   
 
5.  If you want to make changes to your documents after they have been signed and 
witnessed, you must compl ete a new document. 
 
6.  Remember, you can always revoke your Wyoming  document. 
 
7.  Be aware that you r Wyoming document will not be effective in the event of a medical 
emergency.  Ambulance and hospital emergency department personnel are required to 
provide cardi opulmonary resuscitation (CPR) unless they are given a separate directive 
that states otherwise. These directives called “prehospital medical care directives” or 
“do not resuscitate orders” are designed for people whose poor health gives them little 
chance  of benefiting from CPR. These directives instruct ambulance and hospital 
emergency personnel not to attempt CPR if your heart or breathing should stop.    
 
Currently not all states have laws authorizing these orders. We suggest you speak to 
your physician  if you are interested in obtaining one.  Caring Connections does not 
distribute these forms.
Next: Wisconsin Financial Power of Attorney Form Previous: Wisconsin Power of Attorney Revocation Form
If you want to remove Wyoming Medical Health Care Power of Attorney Form from this website please contact us providing the reasons together with this url: https://formsarchive.com/wyoming-medical-health-care-power-of-attorney-form/

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