West Virginia Medical Power of Attorney
This Medical Power of Attorney document is designed to comply with the West Virginia Health Care Decisions Act. It allows you to appoint an individual, known as your Health Care Surrogate, to make health care decisions on your behalf if you become unable to make them yourself. Ensure you choose someone you trust to act in your best interests.
Principal’s Information:
- Full Name: ____________________________________
- Address: ______________________________________
- City, State, Zip: _______________________________
- Primary Phone Number: _________________________
- Date of Birth: _________________________________
Health Care Surrogate’s Information:
- Full Name: ____________________________________
- Address: ______________________________________
- City, State, Zip: _______________________________
- Primary Phone Number: _________________________
- Alternate Phone Number: ________________________
By this document, I, _________________ [Principal’s full name], resident of ___________________ [City, State], designate the following individual as my Health Care Surrogate to make health care decisions for me:
Primary Health Care Surrogate:
Name: ___________________________________________
Relationship to Principal: ________________________
Address: ________________________________________
Phone Number: ___________________________________
Alternate Health Care Surrogate (Optional):
In the event that my primary Health Care Surrogate is unwilling, unable, or unavailable to act on my behalf, I hereby designate the following individual as my alternate Health Care Surrogate:
Name: ___________________________________________
Relationship to Principal: ________________________
Address: ________________________________________
Phone Number: ___________________________________
I grant my Health Care Surrogate authority to make all health care decisions for me, including decisions about medical treatment, surgical procedures, artificial nutrition and hydration, and end-of-life care, subject to any limitations specified in this document.
Limitations on Health Care Surrogate’s Authority (Optional):
If you wish to limit your Health Care Surrogate's authority, describe those limitations here:
_________________________________________________
_________________________________________________
This Medical Power of Attorney becomes effective when I am unable to make my own health care decisions, as determined by a licensed physician.
Signature and Acknowledgements:
This document must be signed in the presence of two witnesses, who will also sign and print their names below. Neither witness should be your Health Care Surrogate.
Principal’s Signature: _______________________________ Date: ____________
Witness #1 Signature: _______________________________ Date: ____________
Print Name: _________________________________________
Witness #2 Signature: _______________________________ Date: ____________
Print Name: _________________________________________
It is recommended to discuss the contents of this document with your Health Care Surrogate, family, and primary physician to ensure your wishes are understood and will be followed.
This template is intended to provide general information and guidance about creating a West Virginia Medical Power of Attorney. It is not a substitute for professional legal advice. Consider consulting with a legal professional to ensure your document complies with current West Virginia laws and accurately reflects your wishes.