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Wyoming Medical Power of Attorney Form

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Wyoming Medical Power of Attorney Form

Updated July 19, 2024

A Wyoming medical power of attorney is a document that allows a person to appoint an attorney-in-fact to make health care decisions on their behalf. The document offers unlimited decision-making powers to the attorney-in-fact to make any decision legal under State law, which includes removing eating and feeding tubes.


“Power of attorney for health care” means the designation of an agent to make health care decisions for the individual granting the power.[1]


How to Write

Download: PDF, MS Word, OpenDocument

1 – Download This Form To Designate A Health Care Attorney-in-Fact

The template to declare the identity of a Health Care Agent in Wyoming is attainable by selecting either the image or the button accompanying it in the caption

2 – Produce The Requested Information To Relegate Each Party To The Appropriate Role

The top of this page will require the County where this document is being executed and notarized. The Preparer of this paperwork should keep in mind the Notary Public attending its execution may require this first space to be filled in at the time of signing. The terminology featured in the body of this template will supply the necessary declaration that should be made when issuing this type of Principal Power. Its contents may be changed at the Principal’s discretion, but this should only be done after an honest consultation with a qualified professional (i.e. Physician, Lawyer, etc.)

The Names of the individuals involved with this document (the Principal and the Health Care Agent). It will be the Principal who is naming the Health Care Agent as an individual who will represent his or her Medical Preferences and Directives. The Principal’s Full Name (First Name, Middle Name, Last Name, and any applicable Suffix) should be presented on the first available line after the words “Know All Men By These Presents That I”The next three available spaces are reserved for the Physical Street Address, County/City/Town, and Zip Code of the Principal’s Address in Wyoming Now locate the phrase “…Hereby Make, Constitute, and Appoint” then document the intended Health Care Agent’s Full Legal Name. The next statement will declare the Health Care Agent has the Principal Authority to arrange for Medical Care for the Principal if the Principal is rendered incapacitated. Furnish the Principal’s Name to the space that precedes “Has The Authority…” Then supply the Attorney-in-Fact’s Name on the second blank space here. Keep in mind that each of these Names should be presented exactly as they are displayed in the first paragraph The final item that must be reported will be the Effective Date of the terms set forth in this paperwork. This information should be entered in the Two-Digit Calendar Day, Month Name, and Two-Digit Calendar Year format using the three blank spaces after the term “…Granted Shall Commence On The”  

3 – The Principal Must Review And Approve This Paperwork

This document will not be valid unless the Principal signs it. Since this signature must be proved as authentic, there will be two separate areas reserved for either the Notary Public or Two (2) Witnesses.

On the day the Principal signs his or her Name, he or she must report the Current Calendar Date using the spaces in the last sentence of this paperwork (beginning with the term “Date This…”). The Principal must then sign his or her Name on the blank line after the last statement and print his or her Name below the signature Following that, the section for witnesses will supply fields for each witness to print, date, and sign the document. Alternately, the section below shall make space for the Notary Public information, such as County Name, Signature, and Seal.