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West Virginia nd this __________ day of _____________, 20____. My commission expires:______________________________________ __________________________________________________________ Notary Public -3- ____________, as witnesses, whose names are signed to the writing above bearing date on the ____________ day of _____________, 20_____, have this day acknowledged the same before me. Given under my ha_______________________ I, ________________________________, a Notary Public of said County, do certify that_________________________________________, as principal, and ____________________ and ______ted: _______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ STATE OF WEST VIRGINA COUNTY OF ________resentative of the principal. Dated: _______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ -2- Da 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 repast 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 theITY TO GIVE, WITHHOLD OR WITHDRAW INFORMED CONSENT TO MY OWN MEDICAL CARE. __________________________________________ (Principal's Signature) I did not sign the principal's signature above. I am at le_______________________________________________ _____________________________________________________________________________ THIS MEDICAL POWER OF ATTORNEY SHALL BECOME EFFECTIVE ONLY UPON MY INCAPAC_____________ _____________________________________________________________________________ _____________________________________________________________________________ ______________________________n may be placed here). My failure to provide special directives or limitations does not mean that I want or refuse certain treatments.) ________________________________________________________________e following SPECIAL DIRECTIVES OR LIMITATIONS ON THIS POWER: (Comments about tube feedings, breathing machines, cardiopulmonary resuscitation, dialysis, funeral arrangements, autopsy and organ donatioake 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 thive and that this document be taken as a formal statement of my desire concerning the method by which any health care -1- decisions should be made on my behalf during any period when I am unable to mis 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 effectrest 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 erstands 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 inte Such authority shall include, but not be limited to, decisions regarding the withholding or withdrawal of lifeprolonging interventions. I appoint this representative because I believe this person undwithdraw 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.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 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 sentative): Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ This appointment shall extend to, but not be disqualified to serve, then the person I choose as my successor representative is (Insert the name, address, area code and telephone number of the person you wish to designate as your successor repreesentative): Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ If my representative is unable, unwilling or 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 reprI,____________________________________________________, (name and address ) hereby appoint my representative to act on my behalf to give, withhold or withdraw informed consent to health care decisionsnd use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -2- STATE OF WEST VIRGINIA MEDICAL POWER OF ATTORNEY Dated: _____________________________ , 20______ lso consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase ad should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should aeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you anerable. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completld to be invalid, such invalidity shall not affect other directions of the living will which can be given effect without the invalid direction and to this end the directions in the living will are seving will may, but need not, be in the following form and may include other specific directions not inconsistent with other provisions of this article. Should any of the other specific directions be hels, nursing homes, personal care homes, community care facilities or any other similar person or group, without separate compensation, does not constitute the unauthorized practice of law. (g) The livmedical power of attorney forms substantially in compliance with this article by health care providers, medical practitioners, social workers, social service agencies, senior citizens centers, hospitaThat under no circumstances may admission to a health care facility be predicated upon a person having completed either a medical power of attorney or living will. (f) The provision of living will or ch person shall be advised of the existence and availability of living will and medical power of attorney forms and shall be given assistance in completing such forms if the person desires: Provided, ll make the living will, medical power of attorney or a copy of either or a revocation of either a part of the principal's medical records. (e) At the time of admission to any health care facility, eaorney. An attending physician or other health care provider, when presented with -1- the living will or medical power of attorney, or the revocation of a living will or medical power of attorney, shatification to his or her attending physician and other health care providers of the existence of the living will or medical power of attorney or a revocation of the living will or medical power of att an operator of a health care facility serving the principal and who is not related to the principal. (d) It shall be the responsibility of the principal or his or her representative to provide for nothe principal; (2) an employee of a treating health care provider not related to the principal; (3) an operator of a health care facility serving the principal; or (4) any person who is an employee ofney representative. (c) The following persons may not serve as a medical power of attorney representative or successor medical power of attorney representative: (1) A treating health care provider of ill; (4) Directly financially responsible for principal's medical care; (5) The attending physician; or (6) The principal's medical power of attorney representative or successor medical power of attor or medical power of attorney shall not be affected when a witness at the time of witnessing such living will or medical power of attorney was unaware of being a named beneficiary of the principal's wted to the principal by blood or marriage; (3) Entitled to any portion of the estate of the principal under any will of the principal or codicil thereto: Provided, That the validity of the living willbsection (d) of this section. (b) In addition, a witness may not be: (1) The person who signed the living will or medical power of attorney on behalf of and at the direction of the principal; (2) Rela of two or more witnesses at least eighteen years of age; and (5) signed and attested by such witnesses whose signatures and attestations shall be acknowledged before a notary public as provided in su2) executed by the principal or by another person in the principal's presence at the principal's express direction if the principal is physically unable to do so; (3) dated; (4) signed in the presencetorney. (a) Any competent adult may execute at any time a living will or medical power of attorney. A living will or medical power of attorney made pursuant to this article shall be: (1) In writing; (ginia Code. The following are useful excerpts from the West Virginia Code relating to the West Virginia Power of Attorney for Health Care Form. §16-30-4. Executing a living will or medical power of at) West Virginia Power of Attorney for Health Care Form (Medical Power of Attorney). This West Virginia Power of Attorney for Health Care is based on Chapter 16 Section 16-30-4 et. Seq. of the West VirInformation and Instructions Power of Attorney for Health Care This package contains (1) Information and Instruction for West Virginia Power of Attorney for Health Care (Medical Power of Attorney); (2 West Virginia