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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: _________________________
I, , of , , hereby appoint 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:
| Representative Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
NOTICE: The following persons may NOT serve as your medical power of attorney representative or successor medical power of attorney representative: (1) Your treating health care provider; (2) An employee of your treating health care provider, unless the employee is your relative; (3) An operator of a health care facility serving you; or (4) Any employee of an operator of a health care facility serving you, unless the employee is your relative.
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. Such authority decisions regarding the withdrawal and withholding of artificially-provided nutrition and hydration (food and fluids).
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 feedings, breathing machines, cardiopulmonary resuscitation, dialysis, 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.)
If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
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: | ________________________________________ |
| Name: |
| Address: |
| County |
I did not sign 's signature above. I am at least eighteen years of age and am not related to by blood or marriage. I am not entitled to any portion of the estate of to the best of my knowlege under any will of or codicil thereto, or legally responsible for the costs of 's medical care or other care. I am not 's attending physician, nor am I the representative or successor representative of .
| Witness Signature: | ______________________________________ |
| Date: | ______________________________ |
| Witness Signature: | _________________________________________ |
| Date: | ______________________________ |
________________________________________
STATE
________________________________________
COUNTY
I, ____________________________, a Notary Public of said County, do certify that ____________________________, as Principal, and ____________________________ and ____________________________, as witnesses, whose names are signed to the writing above bearing date on the ___________ day of ____________________, _______, have this day acknowledged the same before me.
Given under my hand this ____________ day of ___________, _______.
My commission expires: __________________
____________________________________________
NOTARY PUBLIC
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It is simple and easy to grant or receive the support you might need using a free West Virginia Medical Power of Attorney template from Rocket Lawyer:
This solution is, in most cases, notably more affordable than finding and hiring the average lawyer. If needed, you may start a Medical PoA on behalf of a relative, and then help them sign once you've drafted it. Keep in mind that for a PoA form to be accepted as valid, the principal must be an adult who is mentally competent at the time of signing. If the principal is already incapacitated and unable to make their own decisions, a court-appointed conservatorship may be required. When managing this situation, it's a good idea for you to speak to a lawyer .
Every adult ought to have a Medical Power of Attorney. Although it can be painful to think about, there could come a time when you are no longer able to make your own medical decisions. Typical occasions where you might find a PoA to be useful include:
Regardless of whether this West Virginia Medical Power of Attorney is being produced as a result of an unexpected issue or as part of a long-term plan, witnesses and notarization are highly recommended for protecting your document if a third party challenges its authority.
At times, when discussing the topics of estate planning or elder care with medical professionals, you might hear the terms "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" used together. In short, they are the same. That said, it is entirely possible to establish agency over affairs that are not health-related, in which case, "proxy" typically is not the term of choice.
West Virginia Medical PoA forms are normally straightforward; however, you or your agent might need advice. Hiring a legal professional to check your West Virginia Medical Power of Attorney can be time-intensive and relatively expensive. An easier option is via attorney services at Rocket Lawyer. As a Premium member, you can get your documents reviewed or ask specific questions. As always, you can rest assured that Rocket Lawyer will be here to support you.
The fees associated with meeting and hiring a lawyer to draft a Medical Power of Attorney could range anywhere between two hundred and five hundred dollars, depending on your location. Unlike most other Power of Attorney template websites that you may discover, Rocket Lawyer gives Premium membership holders up to a 40% discount when hiring a lawyer, so an attorney can assess the situation and take action if you ever require help.
Your Power of Attorney has its own series of next steps you should take to finalize the document. Feel free to interact with the document in one or all of the following ways: editing it, downloading it as a PDF document or Word file, printing it, and signing it. Finally, you should provide a final copy of your signed document to your agent(s), care providers, and other impacted parties.
The specific guidelines and restrictions governing PoA forms vary by state; however, in West Virginia, your Power of Attorney will require the signatures of two witnesses and a notary public. The witnesses to your form should not be anyone who is financially responsible for your medical care, your attending physician, or any person who signed the PoA document on your behalf, if you are unable to sign. You should also exclude your spouse or any other relative, heir, or beneficiary. As a general standard, witnesses should not be under 18 years old, and no witness should simultaneously be acting as your agent.
See West Virginia Medical/Healthcare Power of Attorney law: § 16-30-4
