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Wyoming Advance Directive Form (Living Will)

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The Wyoming advance directive, also known as a ‘living will’ and includes a power of attorney for health care, is a legal document that allows a person also known as a declarant or principal, to place into writing their personal decisions with regard to how they would like their Attorney in Fact/Agent and/or medical team to arrange for their end of life procedures in the event they are unable to communicate or act on their own behalf. This document may be revoked at any time as long as the declarant is not able.

Definition – 35-22-402(a)(i)

Laws – Title 35, Chapter 22 (Living Will)

Medical Power of Attorney – Select an agent that is able to act on your behalf and recommend any type of health care procedure to physicians if you are not capable of doing it.

How to Write

Step 1 – Download the document. The declarant/principal must take the time to carefully review the information on the first three pages to better educate themselves with regard to what to expect prior to completing this document.

Step 2 – Power of Attorney for Health Care – Designation of Agent – Each page will offer a series of questions. Once all of the questions on the page have been completed, the declarant, at the top of each page, must print their name, enter the date and initial, stating that they have completed each page.

  • Declarant must designate a health care agent to make healthcare decisions on their behalf by providing the following information:
  • Name of person you choose as your agent
  • Address
  • City
  • State
  • Zip Code
  • Home phone
  • Work phone
  • Cell phone

Alternate Agent – To be contacted in the event the first chosen Agent is unable or unwilling to serve. Provide the following information:

  • Name of person you choose as your alternate agent
  • Address
  • City
  • State
  • Zip Code
  • Home phone
  • Work phone
  • Cell phone

Step 3 – Agent’s Authority – The declarant may provide complete permission for their agent to make their healthcare decisions on their behalf EXCEPT for what is typed or written in the line in this section

Step 4 – Agent’s Authority Becomes Effective – The Declarant has options as to when the Agent’s authority will go into effect. Although it can be immediate, generally authority goes into effect when the patient become critical and is no longer going to have the ability to speak for or act on their own behalf.

  • The Declarant has three options available as to when the agent’s authority will go into effect on this form. Select one box and initial the box that best fits your comfort level.

Step 5 – Instructions for Healthcare – The Declarant may select only one box in this section with regard to their end of life option, which should be honored and executed by both the healthcare provider(s) and the Attorney in Fact.

  • The Declarant should also do select whether or not they are wish to have artificial nutrition and hydration by selecting and option for each

Step 5  – Pain Relief – The Declarant may select whether they would like ongoing pain treatment or none at all

  • Initial the box that would offer you the most comfort, emotionally and/or physically
  • If the options available are not enough, complete the lines available in this section to be more specific with regard to your needs and wishes

Step 6 – Organ Donation – If the Declarant would like to make a selection whether or not to donate organs, they may do so in this section. If you choose to donate, indicate that this is something you would like to do and it will be honored and reported to The Wyoming Donor Registry.

  • Check and initial your personal choice

Step 7 – Physician Information – This section will provide contact information with regard the Declarant’s  Physician-

  • Name of physician
  • Address
  • City
  • State
  • Zip Code
  • Phone number
  • AND
  • Declarant’s Information
  • Declarant must print their name
  • Declarant Signature
  • Date of Signature
  • Physical Address
  • City
  • State
  • Zip Code

More Healthcare Information –

  • Name of Healthcare Institution/Hospice
  • Physical Address
  • City
  • State
  • Zip Code
  • Phone number

Step 8 – Signatures – This document requires the signatures of the Declarant and two unrelated witnesses – Under Wyoming State Statute 35-22-403 (b), a witness may not be a treating health care provider, operator of a treating health care facility or an employee of a treating health care facility

Declarant/Principal –

  • Printed Name
  • Signature
  • Date of Signature in mm/dd/yyyy format
  • Address
  • City
  • State
  • Zip Code

Witness 1 –

  • Print Witness Name
  • Address
  • Witness Signature
  • Date of Signature

Witness 2 –

  • Print Witness Name
  • Address
  • Witness Signature
  • Date of Signature

Notarization – If the Declarant would prefer to have this document notarized instead of using witnesses, the notary public will complete this form and authenticate with their state seal.


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