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Wyoming incipal under a will now existing or by operation of law. Signature: _______________________________ Date: _______________ Print Name: __________________________________________________ -2- Wyoming that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the pr_______________________________________________________ At least one (1) of the witnesses shall also have signed the following declaration: I further declare under penalty of perjury under the laws of Print Name: ___________________________________________________ Telephone Number: _____________________________________________ Residence Address: _____________________________________________ ______idence Address: _____________________________________________ _____________________________________________________________ Witness #2: Signature: _______________________________ Date: _______________#1: Signature: _______________________________ Date: _______________ Print Name: ___________________________________________________ Telephone Number: _____________________________________________ Resa community care facility, an employee of an operator of a community care facility, the operator of a residential care facility, nor an employee of an operator of a residential care facility. Witness influence, that I am not the person appointed as attorney in fact by this document, and that I am not a treating health care provider, an employee of a treating health care provider, the operator of to me to be the principal, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue_________________ (Notary Public) -1- OR WITNESSES' STATEMENT I declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally knownf __________________________ ) ) ) Subscribed, sworn to, and acknowledged before me by ________________________________, the principal, this _______ day of ___________, 20____. (Seal) _____________d that I am eighteen years of age or older, of sound mind, and under no constraint or undue influence. Signature: ____________________________________________________ The State of Wyoming The County o _______ day of ____________, 20 ___, and do hereby declare to the undersigned authority that I sign it willingly, that I execute it as my free and voluntary act for the purposes therein expressed, anor attorney-in-fact, unless the attending physician determines that I have decisional capacity. I, ________________________________________________, the principal, sign my name to this instrument thissability or incapacity. The determination of whether I can make my own medical decisions is to be made by my attorney-in-fact, or if he or she is unable, unwilling or unavailable to act, by my successisions to withhold or withdraw any form of life-sustaining procedures. This power of attorney becomes effective when I can no longer make my own medical decisions and is not affected by my physical di_____________________ (telephone number of successor attorney-in-fact) I authorize my attorney-in-fact and my successor attorney-in-fact to make any and all health care decisions for me, including dec______________________________________________ (name of successor attorney-in-fact) ___________________________________________________ (address of successor attorney-in-fact) ________________________ to withdraw consent for any medical care, treatment, service or procedure. In the event the person I appoint is unable, unwilling or unavailable to act as my attorney-in-fact, I hereby appoint: _________________________________ (address of attorney-infact) ___________________________________________________ (telephone number of attorney-in-fact) as my attorney-in-fact to consent to, or reject, orcipal) of _____________________________________________________________, (address) hereby appoint: ___________________________________________________ (name of attorney-infact) _______________________these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -7- Power of Attorney for Health Care I, _______________________________________________________, (name of printtorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. -6- [_] The purchase and use of 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 also consult an aforms 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 and should not be e 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 completeness. [_]These torney. A person who contests the presumption must prove by clear and convincing evidence the principal was incompetent at the time the durable power of attorney for health care was executed. [_] Thes Presumption of principal's capacity. The principal of a durable power of attorney for health care executed in accordance with this article is presumed to be capable of executing a durable power or atar insurance plan, shall condition admission to a facility, or the providing of treatment, or insurance, on the requirement that a patient execute a durable power of attorney for health care. 3-5-213.insurance. No health care provider or residential care facility, health care service plan, insurer issuing disability insurance, self-insured employee welfare plan, or nonprofit hospital plan or simil desire of the principal that health care treatment be restricted or inhibited. 3-5-212. Restriction on execution of durable power of attorney for health care as condition for admission, treatment or g physician to be in a terminal condition. In making health care decisions under a durable power of attorney for health care, an attempted suicide by the principal shall not be construed to indicate aholding or withdrawal of health care pursuant to a durable power of attorney for health care or a living will so as to permit the natural process of dying when the patient is certified by his attendinattempted suicide. Nothing in this article shall be construed to condone, authorize or approve mercy killing, or to permit any affirmative or deliberate act or omission to end life other than the withwal of the health care. In such a case, the case is governed by the law that would apply if there were no durable power of attorney for health care. 3-5-211. Mercy killings; natural process of dying; onsent to health care, or to consent to the withholding or withdrawal of health care necessary to keep the principal alive, if the principal objects to the health care or to the withholding or withdralth care treatment in an emergency. 3-5-210. Principal's objections; governing law. -5- Nothing in this article authorizes an attorney in fact under a durable power of attorney for health care to cained. If the patient is not being maintained in a medical facility, a copy shall be retained by the physician in charge in his own case records. (d) This article does not affect the law governing heaian in charge of the individual who is terminally ill or in an irreversible coma. A copy of any such certification shall be kept in the records of the medical facility where the patient is being maintpetent family members. (c) For purposes of this article, certification of a terminal condition or irreversible coma may be rendered only in writing by two (2) physicians, one (1) of whom is the physicith that the patient, if competent, would choose to forego that treatment. This subsection is not intended to limit existing authority in the family to consent to other forms of medical care for incoms described in this section, a physician may withhold or withdraw life sustaining procedures from that person when all family members who can be contacted through reasonable diligence agree in good fa on behalf of another. (b) When an incompetent person who has not executed a document under this article is certified as suffering from a terminal condition or an irreversible coma under the procedure alive. 3-5-209. Health care decisions on behalf of another; emergency treatment. (a) Subject to W.S. 3-5-204, nothing in this article affects any right a person may have to make health care decisionsre provider or residential care facility is not subject to criminal prosecution, civil liability or professional disciplinary action for failing to withdraw health care necessary to keep the principalith is authorized under this article to make the decision. (b) Notwithstanding the health care decision of the attorney in fact designated by a durable power of attorney for health care, the health carofessional disciplinary action for relying on a health care decision on behalf of a principal made by an attorney in fact who the health care provider or residential care facility believes in good fa care, the provisions of this article and to W.S. 3-5-205 and 3-5-210 through 3-5-212, a health care provider or residential care facility is not subject to criminal prosecution, civil liability, or prminate all or any part of the durable power of attorney for health care. 3-5-208. Immunities of health care provider. (a) Subject to any limitations stated in the durable power of attorney for healthe revocation. -4- (g) If a conservator is appointed for the principal, the conservator has the same power the principal would have had if he were not disabled or incompetent to revoke, suspend or teunder this section, a person is not subject to criminal prosecution or civil liability for acting in good faith reliance upon the durable power of attorney unless the person had actual knowledge of th designation is revoked solely by this subsection, it is revived by the principal's remarriage to the former spouse. (f) If authority granted by a durable power of attorney for health care is revoked principal is divorced or his marriage is annulled, the divorce or annulment revokes any designation of the former spouse as an attorney in fact to make health care decisions for the principal. If anyior durable power of attorney for health care. (e) Unless the durable power of attorney for health care expressly provides otherwise, if after executing a durable power of attorney for health care thes presumed that the principal has the capacity to revoke a durable power of attorney for health care. (d) Unless it provides otherwise, a valid durable power of attorney for health care revokes any prng that the authority granted to the attorney in fact to make health care decisions is revoked, the health care provider shall make the notification a part of the principal's medical records. (c) It iii) Revoke the authority granted to the attorney in fact to make health care decisions by notifying the health care provider in writing. (b) If the principal notifies the health care provider in writi care, the principal may do any of the following: (i) Revoke the appointment of the attorney in fact under the durable power of attorney for health care by notifying the attorney in fact in writing; (on of attorney in fact or durable power of attorney; dissolution or annulment of marriage; immunity. (a) At any time while the principal has the capacity to give a durable power of attorney for healthe principal to receive information regarding the proposed health care, to receive and review medical records, and to consent to the disclosure of medical records. 3-5-207. Principal's powers; revocatight is limited by the durable power of attorney for health care, an attorney in fact designated to make health care decisions under a durable power of attorney for health care has the same right as thatment; or -3- (iii) Psychosurgery. 3-5-206. Attorney in fact; information regarding proposed health care; reception, review and consent to disclosure of medical records. Except to the extent the rih care shall not authorize the attorney in fact to consent to any of the following on behalf of the principal: (i) Commitment to or placement in a mental health treatment facility; (ii) Convulsive treey for health care, to make or participate in the making of health care decisions on behalf of the principal. 3-5-205. Attorney in fact; authority to consent. (a) A durable power of attorney for healtres are unknown, to act in the best interests of the principal. (d) Nothing in this article affects any right the person designated as attorney in fact may have, apart from the durable power of attornact has a duty to act consistent with the desires of the principal as expressed in the durable power of attorney or otherwise made known to the attorney in fact at any time or, if the principal's desir the Uniform Anatomical Gift Act; (ii) Directing the disposition of remains under W.S. 35-4-602. (c) In exercising the authority under the durable power of attorney for health care, the attorney in f the principal, before or after the death of the principal, to the same extent as the principal could make health care decisions for himself including but not limited to: (i) Making a disposition undeect to that decision. (b) Subject to any limitations in the durable power of attorney, the attorney in fact designated in a durable power of attorney for health care may make health care decisions forpal in all matters of health care decisions. However, the attorney in fact does not have authority to make a particular health care decision if the principal is able to give informed consent with respty. (a) Unless the durable power of attorney provides otherwise, the attorney in fact designated in a durable power of attorney for health care has priority over any other person to act for the princiyee so designated is a relative of the principal by blood, marriage or adoption; and (ii) The other requirements of this article are satisfied. 3-5-204. Attorney in fact; health care decisions; priorir of a community care facility or an employee of a residential care facility may be designated as the attorney in fact to make health care decisions under a durable power of attorney if: (i) The emplof community care facility or residential care facility for elderly; designation as attorney in fact; conditions. -2- (a) An employee of the treating health care provider or an employee of an operatocodicil thereto of the principal existing at the time of execution of the durable power of attorney or by operation of law then existing. 3-5-203. Employee of treating health care provider, operator ohe following: (i) A relative of the principal by blood, marriage or adoption; (ii) A person who would be entitled to any portion of the estate of the principal upon his or her death under any will or y; (vii) An employee of an operator of a residential care facility. (d) At least one (1) of the persons used as a witness under subsection (a) of this section shall be a person who is not one (1) of t care provider; (iii) The attorney in fact; (iv) The operator of a community care facility; (v) An employee of an operator of a community care facility; (vi) The operator of a residential care facilitl's treating health care provider. (c) None of the following shall be used as a witness under subsection (a) of this section: (i) A treating health care provider; (ii) An employee of a treating healthpower of attorney; (ii) A health care provider or employee of a health care provider shall not act as an attorney in fact to make health care decisions if the health care provider becomes the principantial care facility nor an employee of an operator of a community care facility or residential care facility, shall be designated as the attorney in fact to make health care decisions under a durable blic. (b) Except as provided in W.S. 3-5-203: (i) Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a community care facility or residef the estate of the principal upon the death of the principal under a will now existing or by operation of law."; -1- (B) The durable power of attorney is sworn to and acknowledged before a notary puher declare under penalty of perjury under the laws of Wyoming that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part othe operator of a residential care facility, nor an employee of an operator of a residential care facility." At least one (1) of the witnesses shall also have signed the following declaration: "I furt 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, ower of attorney 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 attorney in fact by this document,ty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally known to me to be the principal, that the principal signed or acknowledged this durable pe signing of the instrument by the principal or the principal's acknowledgment of the signature or of the instrument, each witness making the following declaration in substance: "I declare under penal execution; (iii) The durable power of attorney is witnessed by one of the following methods: (A) The durable power of attorney is signed by at least two (2) witnesses each of whom witnessed either thng requirements are satisfied: (i) The durable power of attorney specifically authorizes the attorney in fact to make health care decisions; (ii) The durable power of attorney contains the date of itsions on parties designated as attorney in fact; patient advocates or ombudsman. (a) An attorney in fact under a durable power of attorney shall not make health care decisions unless all of the followig Statutes relating to the Wyoming Power of Attorney for Health Care Form. ARTICLE 2 -DURABLE POWER OF ATTORNEY FOR HEALTH CARE 3-5-202. Attorney in fact; health care decisions; requirements; restricty for Health Care Form. This Wyoming Power of Attorney for Health Care is based on Title 30 Chapter 5 Section 3-5202 et. Seq. of the Wyoming Statutes. The following are useful excerpts from the WyominInformation and Instructions Wyoming Power of Attorney for Health Care This package contains (1) Information and Instruction for Wyoming Power of Attorney for Health Care; (2) Wyoming Power of Attorne Wyoming