West Virginia Health Care Power of Attorney FormWest Virginia Health Care Power of Attorney Form
Download the document to the computer for easy use
There are more pages to preview,Read on

STATE OF WEST VIRGINIA

MEDICAL POWER OF ATTORNEY
The Person I Want to Make Health Care Decisions
For Me When I Can’t Make Them for Myself

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 person you wish to designate as your
representative)
The person I choose as my successor representative is:
If my representative is unable, unwilling or disqualified to serve, then I appoint
_____________________________________________________________________________________
(Insert the name, address, area code and telephone nu