West Virginia Advance Directive Form

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A West Virginia advance directive is a form that combines several health planning documents to allow a person to select their end-of-life treatment options. The form also allows a person to select someone else, an “agent”, to act in their place and make medical decisions if the patient cannot due so for themselves. The agent must make decisions in accordance with the medical requests written in the advance directive.

Advance Directive Includes

Table of Contents

Laws

StatuteChapter 16, Article 30 (West Virginia Health Care Decisions Act)

Signing Requirements (§ 16-30-4) – Two (2) witnesses and a notary public.

Versions (4)


AARP

Download: Adobe PDF

 

 

 


Center for End of Life Care

Download: Adobe PDF

 

 

 


Grant Memorial

Download: Adobe PDF

 

 

 


Mental Health Advance Directive

Download: Adobe PDF

 

 

 


How to Write

Download: Adobe PDF

Step 1 – Acquire Your Copy Of The West Virginia Advance Health Care Directives

Utilize either the “Adobe” button captioning the form you wish to download or the “Adobe PDF” link in this section of the page to access the West Virginia Advance Directives to your computer.

Step 2 -Display Your Intention To Register Your Paperwork And Identify yourself

The West Virginia Medical Power Of Attorney is the first issuance in this package. This document is useable as a tool to appoint a person to represent the West Virginia Principal or Patient seeking representation. Before proceeding with this task, locate the box at the top of the page beginning with the words “Opt In.” If you intend to register your Medical Power of Attorney with the West Virginia E-Directive Registry, then select this box by place a checkmark or an ‘x’ in it. If you do not mark this checkbox it will be understood that you currently do not have any such intention. After making this determination and presenting it accordingly move to the right then furnish a production of your last name, first name, and middle initial to the blank line labeled “Last Name/First/Middle” and a presentation of your home “Address” to the two lines that follow. 

 

Step 3 – Support Your Identity As The West Virginia Declarant With Additional Information

Your name is usually sufficient to identify yourself on quite a bit of paperwork however due to the ramifications of this document as well as the subject matter, West Virginia Doctors will wish to make sure that they are reviewing the correct document for their Patient. Thus, continue with a report of your birth day on the “Date Of Birth” line. The four-digit at the end of your social security number should also be presented. Supply them to the blank lines labeled “Last 4 SSN’ then moving to the right, place a mark in either the checkbox labeled “M” or the checkbox labeled “F” to solidify your sex to attending West Virginia Doctors. Your “Email Address” is the next piece of information to be delivered. Use the final line in this box to display this. 

 

Step 4 – Furnish The Official Date Of Your West Virginia Medical Power Of Attorney

To begin the appointment of a West Virginia Health Care Representative, locate the line labeled “Date” then supply the calendar day, month, and year when this paperwork is completed. Typically, this is the same day as the signature date when the West Virginia Patient, referred to as the Principal, executes this document. 

 

Step 5 – Supplement The West Virginia Declaration Statement

The first line of the opening statement will need to be supplied with the West Virginia Principal’s full name and address. Locate this line, easily noticed through the “Insert Your Name And Address,” then furnish the full name of the West Virginia Principal as well as his or her address to this line. The West Virginia Principal in this document is the Patient who wishes to grant his or her authority over treatment decisions to another person that can represent these preferences or directives effectively.

 

Step 6 – Deliver The Medical Power To Represent You To The West Virginia Health Care Agent

The individual who will be granted authority to convey the Principal’s medical directives, consents, and refusal to West Virginia Medical Personnel on behalf of the Principal is termed the West Virginia Health Care Representative, Attorney-in-Fact, or simply Agent. Produce the complete name, address, and telephone number of the person the West Virginia Principal intends to grant with the authority to act as his or her West Virginia Health Care Representative on the blank lines that follow the statement “The Person I Choose As My Representative Is”   

 

Step 7 – Appoint The Successor To The West Virginia Health Care Agent Position

The West Virginia Health Care Representative may not always be available, able, or even willing to carry out the role designated to him or her. You can make sure that should this occur while you are unconscious for an extended time period, West Virginia Doctors could be left without anyone carrying the authorization to consent or deny treatment that reflect your preferences or expectations. The statement “The Person I Choose As My Successor Representative” presents a set of blank lines that can be utilized to name a second person to this role if, and only if, the original choice can or will no longer carry this role. These lines require the name, address, and phone number of this Successor.

 

Step 8 – Attach Your Name To The Completed First Page

The blank line labeled “Principal Name” should be populated with your name. This identifies the completed page as an acknowledged part of your directive.

 

Step 9 – Review The West Virginia Medical Decision-Making Power Being Granted

The abilities the West Virginia Health Care Representative carries to view your records, confer with your Health Care Provider(s) regarding your treatment, deliver your consent, and refuse procedures using your name is discussed in the body of this power document. It is crucial that you as the West Virginia Principal read through this passage making sure to comprehend every point made.

 

Step 10 – Include Special Directives Or Limitations In Your West Virginia Declaration

If desired, you may add to the powers that will be granted to the West Virginia Health Care Representative by recording specific instructions, general preferences, guidelines that your West Virginia Health Care Representative, restrictions placed on his or her power of representation or even circumstances that dictate what he or she can or cannot do in your name. All such instructions should be supplied to the blank lines closing the Medical Power Of Attorney being completed.

 

Step 11 – Document Your Intent And Your Signature Date For Your Appointment

The appointment of your West Virginia Health Care Agent cannot be made unless you, as the Principal Patient, sign this document after it has been completed and with all attachments present. Produce your signature on the blank line preceding the “Date” label then, after this label, supply the current “Date.” 

 

Step 12 – Display The Confirming Signatures Of Two Witnesses

The paragraph presented in the next section is a statement confirming the West Virginia Principal’s signing as authentic and that it has been witnessed (physically) by the two Signature Parties that follow. The Witnesses of your signing must read this statement. The first line labeled “Witness” requires the signature of one of these individuals while the line to the right requests the signature “Date.”  The next Witness should sign the second “Witness” line and produce the “Date” when he or she is making this confirmation may signature. 

 

Step 13 – Notarize The West Virginia Execution Of These Directives

A distinguishable area has been reserved for the notarization process your West Virginia Notary Public will subject the newly signed directive to. He or she will take control of this paperwork then, according to the local procedural requirements, record his or her identity, that of the West Virginia Signature Principal, both Witnesses, and the date of your signature action. This area will also accept his or her information, credentials, and seal as needed.

 

Step 14 – Document Your Standing As A West Virginia E-Directive Registrant With Your Identity

If you intend to register this paperwork with the WV E-Directive Registry so that it may be released to treating Health Care Providers as needed, then select the box labeled “Opt In” at the top of this page. If not, then leave this box blank. On the right, the blank line labeled “Last Name/First/Middle” to furnish your name as the West Virginia Patient behind this paperwork. This area also seeks your home address on the lines labeled “Address” and “City/State/Zip”

 

Step 15 – Furnish Useful Background Information

In addition to your E-Directive standing, name, and address this area will seek additional identifiers with a request for your “Date Of Birth” on the appropriately blank line. The next two labels seek the last four numbers in your social security number recorded after the words “Last 4 SSN” as well as a selection of either the “Male” checkbox or “Female” checkbox to indicate your “Sex.” Finally document your “Email Address” on the final line of the header.

 

Step 16 – Date The West Virginia Living Will

The West Virginia Living Will requires a specific date set to its effect. This date is expected as a two-digit “Day Of” the month on the first empty line after the words “…Made This” then the name of the month and the four-digit year on the line labeled “Month, Year” 

 

Step 17 – Supplement The West Virginia Declaration With Your Name

The declaration made to West Virginia Doctors through this paperwork will convey your intent to deny life-prolonging treatment when you are unable to communicate and are formally diagnosed by at least one Physician that you have a terminal condition (resulting in death) or in a “Persistent Vegetative State” where there is no true hope of recovery. To proceed with this statement, locate the blank line at its onset (preceding “Being Of Sound Mind, Willfully And Voluntarily Declare…”) then supply your name as the person making this statement. It is strongly recommended that you read through the West Virginia Living Will that you have just produced your name to. 

 

Step 18 – Inform West Virginia Providers Of Any Remaining Directives

The blank lines set near the end of this declaration are reserved for your use. Here, you may directly address West Virginia Health Care Providers that will care for you if you are unconscious and/or unable to communicate your treatment preferences. If you have conditions that you wish placed on life-prolonging procedures, restrict West Virginia Doctors from administering certain techniques altogether, or request specific types of intervention then record such instructions accordingly. If more room is needed to adequately define your instructions, then continue on a separate page(s) making sure to list the title as an attachment on these lines.

 

Step 19 – Supply Your Name As The Principal Completing The Living Will

The blank line after the parenthesis term “Person For Whom Form Is Being Completed” requires your name to solidify this page is part of your directive. 

 

Step 20 – Prove Your Acknowledgement And Intent Of this Declaration

Locate the statement “I Understand The Full Import Of this Living Will” then furnish your signature and signature “Date” as the West Virginia Declarant to the two lines, starting with the one labeled “Signed.” Furnish your home “Address” on the next line to complete your West Virginia Living Will.

 

Step 21 – Obtain Witness Confirmation Of Your Signature

Two Witnesses and a Notary Public should watch your West Virginia Declarant act of signing. The Witnesses must both read the statement made immediately following your signature. The First Witness in control of this document should sign his or her name and enter the current day, month, and year on the first row of lines labeled “Witness” and “Date.” The Second Witness in attendance must sign the second “Witness” line and document the “Date” he or she signed this document on the adjacent line.

 

Step 22 – Have This Execution Notarized By A West Virginia Notary

The final section of the living will can only be completed by a Notary Public commissioned to operate in West Virginia. He or she must document the location, Parties in attendance, and signature date of your declaration’s signing during the notarization process then prove the completion of this process with his or her credentials. 

 

Step 23 – Deliver The Required Patient Authorization For The WV E-Directive Registry

For your West Virginia Health Care Representative to receive your information, your authorization must be provided. While this is not a formal part of your directive, when information is requested from the West Virginia E-Directive, this request will need to be accompanied by the “Patient Authorization For Release Of Information From The WV E-Directive Registry.” Keep this form on file for future use. 

 

Step 24 – If Desired, Complete The West Virginia E-Directive Registry Sign-Up Form

To register the West Virginia Directive, locate the last page of this template then mark the box labeled “Opt In.”  Once you have selected the “Opt In” box, enter your full name to the text field labeled “Last Name/First/Middle Initial” then furnish your “Date Of Birth” to the adjacent field. Utilize the next two textboxes as a display area for your home address.
Next, indicate your “Gender” by selecting the “Male” checkbox or “Female” checkbox. The “Last 4 Numbers Of Your Social Security Number” should now be produced to the text box provided. The final checkbox should only be marked if your package is sent only to provide “Demographic Updates For Previously Submitted Advance Directive Forms…” When complete, fax, or mail this form with your signed and notarized West Virginia Advance Directive to the WV E-Directive Registry whose information is provided. 

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