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West Virginia Medical Power of Attorney Form

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The West Virginia medical power of attorney may be used by a West Virginia resident to appoint someone who will be in place and available to take over medical care decisions, only in the event that the person doing the appointing is deemed by competent physicians to be incapable of making his or her own decisions. This can provide peace of mind, knowing that you have someone who knows you ready to step in if needed to take over these matters on your behalf.

Definition – § 16-30-3(q)

Laws –  Chapter 16, Article 30 (West Virginia Health Care Decisions Act)

Living Will – Allows a patient to write in their own treatment requests if they should be in a terminally ill state. The requests shall be in reference to pain medication, artificial breathing, and IV for food and hydration.

Durable (Financial) Power of Attorney – You can use this form much as you would a medical power of attorney; select a loved one or trusted agent to oversee your finances.

How to Write

1 – Download A Copy Of This Template To Delegate Health Care Authority To An Agent

Obtain your copy of this directive by selecting it from the buttons presented in the caption area of the preview image.

2 – Satisfy The Beginning Of This Document’s Requirements

The first two blank lines follow the label “Dated.” Enter the Date of this document as a Month Name and Calendar Day on the first blank line and the Two-Digit Year on the second blank line.

Locate the label “Insert Your Name And Address” and the blank line it applies to. Report the Full Name and Address of the person appointing an Agent with the Authority to make Health Care Decisions on his or her behalf. This person is the Principal in the relationship defined through this document and whose signature is mandatory for its execution.On the blank line bearing the label “Insert The Name, Address, Area Code And Telephone Number Of The Person You Wish To Designate As Your Representative” then record the Full Name, Address, and Contact Telephone Number of the Agent who will accept and wield the Principal Authority required to make Health Care Decisions on behalf of the Principal.Locate the third labeled line “Insert The Name, Address, Area Code And Telephone Number Of The Person You Wish To Designate As Your Successor Representative” The Successor Representative will only be able to assume and wield Principal Authority to make Health Care Decisions for the Principal if the Health Care Agent cannot. Enter this person’s Name, Address, and Phone Number(s) on this line.

3 – Deliver Any And All Special Directives Or Instructions

While the body of this form will define the Principal Authority being delivered, it exists as a general statement that can be used in most situations. Some tailoring may be required so this Directive can accurately. This can be done using the blank lines below the statement beginning with the words “I Am Giving The Following Special Directives Or Limitations On This Power…” Here, the Principal can specifically name Health Care Treatments that he or she wants and does not want. Subjects such as spiritual or religious concerns, family matters, and cost may be applied to life-prolonging treatment, quality of life, pain management, and medical interventions. These are only some of the issues that can be addressed in this section. This area should be a full description of the Principal’s Directives and Preferences.

4 – The Principal Must Supply An Acknowledgment Signature Of Execution

The Principal must sign his or her Name once this document has been completed and any Special Directives attached. This action can be performed on the second page on the blank line label “Signature Of Principal.” Two Witnesses to the Principal Signature will also have to supply a Signature of Acknowledgment. A testimonial has been supplied below the Principal’s Signature for this purpose. Each Witness must sign the “Witness” line below this statement and supply the Signature Date on the “Date” line.This signing must be Notarized. The area following the Witness Signature section will supply a place for the Notarization Process to occur.


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