West Virginia Combined Medical Power of Attorney And Living Will FormWest Virginia Combined Medical Power of Attorney And Living Will FormWest Virginia Combined Medical Power of Attorney And Living Will Form
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INITIAL box if you agree to have

this advance directive submitted to the WVe-Directive
Registry, and released to treating health care providers.
Complete information to RIGHT.

REGISTRY FAX: 304-293-7442

Last Name/First/ Middle
Address
City/State/Zip
Date of Birth (mm/dd/yyyy) ______/______/_________
Last 4 SSN ___ ___ ___ ___ Gender M___ F___

STATE OF WEST VIRGINIA
COMBINED
MEDICAL POWER OF ATTORNEY
AND LIVING WILL
The Person I Want to Make Health Care Decisions
For Me When I Can't Make Them for Myself
And
The Kind of Medical Treatment I Want and Don't Want
If I Have a Terminal Condition or Am In a Persistent Vegetative State

Dated:

, 20

I,

, hereby

(Insert your name and address)
appoint 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
The person I choose as my representative is:

(Insert the name, address, area code and telephone number of the pe