This required section states the name and address of the person appointed to make health care decisions if the Principal is unable to do so. There are limits on who may act as the Representative. Press [Ctrl+F1] for more information.
This required section concerns the authority given to the Representative. The Principal grants full power to the Representative to make health care decisions if the Principal is unable to do so. Press [Ctrl+F1].
This optional section states the Principal's wishes regarding life-prolonging procedures which artificially postpone death, and desires regarding artificial food and nutrition. Press [Ctrl+F1] for more information.
This optional section gives the Principal the opportunity to include special provisions concerning health care which are not otherwise contained in the document. Press [Ctrl+F1] for more information.
In this optional section the Principal may specify any values or preferences, such as religious beliefs, location of care or personal values, which pertain to this document. Press [Ctrl+F1] for more information.
This required section enables the Principal to establish specific limitations upon the decision making authority of the Representative. Press [Ctrl+F1] for more information.
This optional section states whether or not the Representative has authority to make anatomical gifts for medical purposes, authorize an autopsy or direct disposition of remains. Press [Ctrl+F1] for more information.
This is an optional section which states that if the original Representative is not available, an alternate Representative will assume responsibility of the original Representative. Press [Ctrl+F1] for information.
In this optional section, the Principal may designate a person to be his/her guardian if one needs to be appointed. Press [Ctrl+F1] for more information.
This required section states that any person or entity who faithfully carries out the terms and provisions of this document shall not be held liable for any damages which may occur. Press [Ctrl+F1] for more information.
This required section prevents the entire document from being invalidated if any provision of the document is declared invalid. Press [Ctrl+F1] for more information.
By signing this required section, the Principal will acknowledge full understanding of the document contents as well as the effects of the granting of powers to the Representative. Press [Ctrl+F1] for information.
This section requires the signature of two witnesses. The witness statement describes limits on who may act as a witness. Press [Ctrl+F1] for more information.
This section requires the signature of a Notary Public to acknowledge that the Principal signed the document. Press [Ctrl+F1] for more information.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Press [Ctrl+F1] for more information.
Times New Roman
Health Care POA
HCP_WV
The Health Care Power of Attorney is a document under which a competent adult (a Principal), prior to becoming unconscious or incompetent, declares his/her intention that life-sustaining procedures should be withheld or withdrawn under certain circumstances, and designates a person who will have authority to make health care decisions for the Principal, if the Principal is unable to do so.
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
HWV01
! Designation of Health Care Representative Section (1 of 15)
MEDICAL POWER OF ATTORNEY
Dated this _____ day of _______________, 19___.
!. DESIGNATION OF HEALTH CARE REPRESENTATIVE.
I, !, hereby appoint:
Representative Name: !
Representative Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Home Phone: !
Work Phone: !
Relation, if any: !
as 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.
NOTICE: The following persons may not serve as a Representative or Successor Representative:
(1) Your treating health care provider;
(2) an employee of your treating health care provider not related to you;
(3) an operator of a health care facility serving you; or
(4) an employee of an operator of a health care facility not related to you.
This required designation section states the name and address of the person appointed as Health Care Representative. The Representative will make health care decisions for the Principal if he/she is unable to make such decisions. Press [Ctrl+F1] for more information.
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Enter the Representative's name or use the P.I. Manager to select and paste a record. Note the limits on who may serve as Representative which appear later in this section. The Representative will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
Enter the Representative's street address or edit the information as desired.
Enter the Representative's extended street address or edit the information as desired.
Enter the Representative's city or edit the information as desired.
Enter the Representative's state/province or edit the information as desired. When naming a Representative, consider the availability of the Representative to confer with health care providers and access medical records and information.
Enter the Representative's zip/postal code or edit the information as desired.
Enter an X to include the Representative's country. If the Representative resides in a different country, he/she may not be available to discuss medical decisions with the health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Representative may be reached during non-business hours.
Enter a phone number at which the Representative may be reached during business hours, if different from the home phone number.
Enter the relationship of the Representative to the Principal.
HWV02
! Authority of Representative Section (2 of 15)
!. GENERAL STATEMENT OF AUTHORITY GRANTED. This appointment shall extend to (but not be limited to) 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 act on my behalf to consent to, refuse or withdraw any and all medical treatment or diagnostic procedures, 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, the withholding or withdrawal of life-prolonging intervention when in the opinion of two physicians who have examined me, one of whom is my attending physician, such life-prolonging intervention offers no medical hope of benefit.
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 interests 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. In the event that the law does not recognize this document as legally binding and effective, it is my intent 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.
My Representative shall have the authority to give, withhold or withdraw informed consent for my health care, which authority shall include, but not be limited to, the following, unless I expressly provide to the contrary:
(1) Make 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;
(2) Permit or gain access to all medical records;
(3) Acknowledge receipt of notifications of rights or responsibilities and any applicable rules of medical or health care facilities;
(4) Employ or discharge medical providers;
(5) Make decisions about measures for the relief of pain;
(6) Consent to, refusing or withdrawing any and all medical treatment or diagnostic procedures, including, but not limited to, life- prolonging intervention when in the opinion of two physicians who have examined the Principal, one of whom being the Principal's attending physician, such life-prolonging intervention offers no medical hope of benefit;
(7) Make decisions about the gift or donation of a body organ or tissue;
(8) Enforce a declaration made pursuant to the West Virginia Natural Death Act, as provided in chapter sixteen (Section 16-30-1 et seq.), article 30, provided, that where the provisions of such a declaration and this Medical Power of Attorney are in conflict, the provisions of the document executed later in time shall control or govern.
In exercising the authority under this Medical Power of Attorney, my Representative shall act consistently with my special directives or limitations as stated below.
This required section states the duties and powers of the Representative on behalf of the Principal. The health care decisions made by the Representative must be consistent with the desires of the Principal as stated in this document, or otherwise known to the Representative. Press [Ctrl+F1] for information.
HWV03
! Optional Life-Prolonging Intervention Section (3 of 15)
!. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING CARE,
TREATMENT, SERVICES AND PROCEDURES: [Choose one of 5 choices; last choice allows you to compose your own statement.]
! I specifically direct my Representative to follow any "living will" executed by me.
! I do not want my life to be prolonged nor do I want life-prolonging intervention to be provided or continued if my Representative believes the burdens of the treatment outweigh the expected benefits. I want my Representative to consider the relief of suffering, my personal beliefs, the expense involved and the quality as well as the possible extension of my life in making decisions concerning life-prolonging intervention.
! I do not want my life to be prolonged and I do not want life-prolonging intervention, except to the extent deemed necessary to provide me with comfort care,
! if I have a condition that is incurable or irreversible and, without the administration of life-prolonging intervention, expected to result in death within a relatively short time.
! if I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
! if I have a condition that is incurable or irreversible and, without the administration of life-prolonging intervention, expected to result in death within a relatively short time, or if I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
! I want my life to be prolonged to the greatest extent possible within the standards of accepted medical practice, without regard to my condition, the chances I have for recovery, or the cost of the procedures.
! [User to compose own statement of desires concerning life-prolonging intervention]
! [Optional Nutrition and Fluids Paragraph]
!. STATEMENT OF DESIRES CONCERNING NUTRITION AND FLUIDS. Artificially provided nutrition or fluids provided by means of a nasogastric tube or tube into the stomach, intestines, or veins,
! shall
! shall NOT
be among the "life-prolonging interventions" that may be withheld or withdrawn under the conditions given above.
Enter an X to include a section concerning the Principal's wishes regarding life-prolonging intervention. States may define this term differently, but generally it means procedures which artificially postpone death. Press [Ctrl+F1] for more information.
Enter an X if the Representative is to follow any "living will" executed by the Principal. A living will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that life-prolonging intervention be withdrawn or withheld under certain conditions.
Enter an X if the Principal gives the Representative the discretion to decide if and when life-prolonging intervention may be withheld or withdrawn. The Representative will decide if the burdens of such life-prolonging intervention outweigh the benefits.
Enter an X if the Principal desires that life-prolonging intervention be given only to the extent of providing the Principal with comfort care.
Enter an X to withhold life-prolonging intervention if the condition of the Principal is incurable or irreversible.
Enter an X to withhold life-prolonging intervention if the Principal is in a permanently unconscious condition.
Enter an X to withhold life-prolonging intervention if the Principal's condition is incurable or the Principal is in a permanently unconscious state.
Enter an X if the Principal desires every possible procedure to be taken to prolong life to the greatest extent, regardless of cost or chances for recovery.
Enter an X if the Principal desires to compose a separate statement of desires concerning life-prolonging intervention. Any of the above statements may be edited or additional statements may be composed.
Use this space to indicate desires concerning life-prolonging intervention.
Enter an X to include a section regarding artificially administered nutrition and fluids.
Enter an X if artificial nutrition and fluids SHALL be among the life-prolonging intervention that may be withheld or withdrawn by the Representative's authorization.
Enter an X if artificial nutrition and fluids SHALL NOT be among the life-prolonging intervention that may be withheld or withdrawn by the Representative's authorization.
IGN06
! Optional Special Provisions Section (4 of 15)
!. SPECIAL PROVISIONS REGARDING MY HEALTH CARE. (For example, describe your wishes regarding any treatment you desire or do not desire, or admission to a residential care facility.)
Enter an X to include a section regarding special provisions concerning health care which are not otherwise contained in the document. For example, describe any types of treatment you wish or wish not to receive. Press [Ctrl+F1] for more information.
Use this space to describe any additional special provisions.
IGN07
! Optional Values and Preferences Section (5 of 15)
!. STATEMENT OF VALUES AND PREFERENCES. (Specify any other wishes, values, religious beliefs, philosophy or other personal values or preferences that are relevant to your instructions. You may also state preferences concerning the location of your care.)
Enter an X to include a section concerning values and preferences about health care. For example, describe values or religious preferences, or the location of treatment. Press [Ctrl+F1] for more information.
Use this space to specify values and preferences.
HWV06
! Limits on Representative's Authority Section (6 of 15)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY REPRESENTATIVE: (If none, write "none.")
This required section enables the Principal to establish limitations on the authority given to the Representative. For example, the Principal may wish to prohibit the Representative from authorizing certain procedures. Press [Ctrl+F1] for more information.
Use this space to specify any limitations on the Representative's authority to make decisions on behalf of the Principal. For example, the Principal may wish to prohibit the Agent from authorizing certain procedures. If there are no limitations, type "none". Press [Ctrl+F1] for more information.
IWV07
! Optional Autopsy, Anatomical Gifts, Disposition of Remains Section (7 of 15)
!. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS.
! I authorize my Representative, to the extent permitted by law,
! I do not authorize my Representative
to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains.
Enter an X to include a section which states whether or not the Representative has the authority to make anatomical gifts, authorize an autopsy, and decide upon the disposition of the Principal's remains. Press [Ctrl+F1] for more information.
Enter an X if the Representative WILL be authorized (to the extent permitted by law) to make decisions concerning anatomical gifts, autopsies, and the disposition of the Principal's remains.
Enter an X if the Representative WILL NOT be authorized to make decisions concerning anatomical gifts, autopsies, and the disposition of the Principal's remains.
HWV08
! Optional Designation of Alternate Representative Section (8 of 15)
!. DESIGNATION OF ALTERNATE REPRESENTATIVE. If the person designated as my Representative is not available or unable to act, I designate the following persons to serve as my Representative to make health care decisions for me as authorized by this document, who serve in the following order:
FIRST ALTERNATE REPRESENTATIVE
Representative Name: !
Representative Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Home Phone: !
Work Phone: !
SECOND ALTERNATE REPRESENTATIVE
Representative Name: !
Representative Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Home Phone: !
Work Phone: !
Enter an X to designate an Alternate Representative. If the original Representative resigns or is unable to perform, an Alternate Representative will be appointed. Generally, the designation of the Principal's spouse as Representative is revoked upon divorce. Press [Ctrl+F1] for more information.
Enter the Alternate Representative's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Representative's street address or edit the information as desired.
Enter the Alternate Representative's extended street address or edit the information as desired.
Enter the Alternate Representative's city or edit the information as desired.
Enter the Alternate Representative's state/province or edit the information as desired. When naming an Alternate Representative, consider the availability of the Alternate Representative to confer with health care providers.
Enter the Alternate Representative's zip/postal code or edit the information as desired.
Enter an X to include the Alternate Representative's country. If the Alternate Representative resides in a different country, consider the availability of the Representative to discuss medical records or information with health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Alternate Representative may be reached during non-business hours.
Enter a phone number at which the Alternate Representative may be reached during business hours, if different from the home phone number.
Enter an X to include the name of a Second Alternate Representative. You do not have to name a Second Alternate Representative.
HWV09
! Optional Nomination of Guardian Section (9 of 15)
!. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate
! my Representative (or Alternate Representative)
Name: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
to serve as my Guardian.
Enter an X to include a section that allows the Principal to nominate a person to serve as the Principal's Guardian if one is required by legal proceedings. This person will be appointed if the Court finds that such appointment is in the Principal's best interests. Press [Ctrl+F1] for more information.
Enter an X if the nominated Guardian will be the Representative (or Alternate Representative).
Enter an X if the nominated Guardian will be someone other than the Representative.
Enter the Guardian's name or use the P.I. Manager to select and paste a record.
Enter the Guardian's street address or edit the information as desired.
Enter the Guardian's extended street address or edit the information as desired.
Enter the Guardian's city or edit the information as desired. The Guardian will need to be available to act for the Principal.
Enter the Guardian's state/province or edit the information as desired.
Enter the Guardian's zip/postal code or edit the information as desired.
Enter an X to include the Guardian's country, if outside the United States. It is very unlikely that a court would appoint a person living in another country as a Guardian for the Principal.
Enter the country or edit the information as desired.
IGN16
! Hold Harmless Section (10 of 15)
!. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
This is a required section in which the Principal states that the Agent and anyone who relies upon any representation by the Agent shall not be liable to the Principal or any interests involved with the Principal. Press [Ctrl+F1] for more information.
HWV11
! Severability Section (11 of 15)
!. SEVERABILITY. 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 required section prevents the entire document from being invalid just because one of the provisions is invalid. Press [Ctrl+F1] for more information.
HWV12
! Signature Section (12 of 15)
THIS MEDICAL POWER OF ATTORNEY SHALL BECOME EFFECTIVE ONLY UPON MY INCAPACITY TO GIVE, WITHHOLD OR WITHDRAW INFORMED CONSENT TO MY OWN MEDICAL CARE.
These directives shall supersede any directives made in any previously executed document concerning my health care.
________________________________________
Signature
Principal Name: !
Principal Address:City: !
County: ! County
State: !
! Country: !
! SSN: !
This section requires the signature of the Principal in the presence of two witnesses and a Notary Public. If this procedure is not followed, the document may be invalid. Press [Ctrl+F1] for more information.
Enter the Principal's city or edit the information as desired. The name was transferred from a previous section and can be modified only by returning to that section.
Enter the Principal's county/parish or edit the information as desired.
Enter the Principal's state/province or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Principal's social security number (SSN). By including the social security number, a health care facility is able to file advance health care directives for future reference. Press [Ctrl+F1] for more information on the Patient Self Determination Act.
Enter the Principal's social security number or edit the information as desired.
HWV13
! Witness Signature Section (13 of 15)
THIS MEDICAL POWER OF ATTORNEY MUST BE (1) SIGNED IN THE PRESENCE OF TWO OR MORE WITNESSES AT LEAST 18 YEARS OF AGE AND (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.
I did not sign the Principal's signature above. I am at least 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 according to the laws of Intestate Succession Act of the state of the Principal's domicile or to the best of my knowledge under any will of the 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 (Alternate) Representative of the Principal.
This section requires the signatures of two witnesses. By signing this section, the witnesses declare that they were present when the Principal signed this document. Note the limits on who may serve as a witness. Press [Ctrl+F1] for more information.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
HWV14
! Notary Section (14 of 15)
STATE OF WEST VIRGINIA,
COUNTY OF _________________________, to-wit:
I, ________________________________________, a Notary Public of said County, do certify that !, as Principal, and ! and !, as witnesses, whose names are signed to this writing above bearing date on the _____ day of _______________, 19___, have this day acknowledged the same before me.
Given under my hand this _____ day of _______________, 19___.
My commission expires: _________________________
________________________________________
Notary Public
This section requires the signature of a Notary Public to acknowledge that the Principal signed this document. The Principal's name and witness names were transferred from previous sections and can be modified only by returning to those sections. Press [Ctrl+F1] for more information.
DOM01
! Health Care Document Information Section (15 of 15)
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record.
The Health Care Power of Attorney should be reviewed:
- if the Agent or the Alternate Agent is no longer able to serve;
- if the Agent is your spouse and you become separated or divorced;
- if you wish to revise your desires as stated in the document.
It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Generally, the Agent, family, and health care provider are given a copy. This section will not print as part of the document. Press [Ctrl+F1] for more information.
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