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.
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/