Combined Medical Power of Attorney and Living Will - West Virginia
STATE OF WEST VIRGINIA
COMBINED
MEDICAL POWER OF ATTORNEY
AND LIVING WILL
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 number of the person you wish to
designate as your successor representative)
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
Opt In
INITIAL box if you agree to have
this advance directive submitted to the WV
e-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___
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