Medical Power of Attorney - West Virginia
Rev. 04/2000
The Person I Want to Make Health Care Decisions
For Me When I Can’t Make Them for Myself
STATE OF WEST VIRGINIA
MEDICAL POWER OF ATTORNEY
Dated:_____________________________ , 20__ ____
I,____________________________________________________ ,
(Insert your name and address)
hereby 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)
This appointment shall extend to, but not be limited to, health care 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 be granted access to my medical records
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