Download West Virginia Combined Medical Power of Attorney And Living Will Form for Free

(4.1 based on 301 votes)
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___
Print Form
West Virginia Combined Medical Power of Attorney And Living Will Form
 1 / 3 >