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West Virginia Medical Power of Attorney Form

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West Virginia Medical Power of Attorney Form

Updated August 09, 2023

A West Virginia medical power of attorney allows a principal to choose a health care representative to make medical decisions on their behalf. The principal can make special limitations or powers to the agent, such as removing breathing or feeding machines if terminally ill. The form only becomes available for use if the principal is incapacitated.


  • “Medical power of attorney representative” or “representative” means a person, 18 years of age or older, appointed by another person to make health care decisions pursuant to § 16-30-6 of this code or similar act of another state and recognized as valid under the laws of this state.

How to Write

Download: PDF

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.