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REGISTRY FAX: 844-616-1415 Last Name/First/Middle Address City/State/Zip Date of Birth (mm/dd/yyyy) // Last 4 SSN Gender M F STATE OF WEST VIRGINIA MEDICAL POWER OF ATTORNEY The Person I Want to Make Health Care Decisions For Me When I Can t Make Them for Myself Dated: , 20 , hereby I, (Insert your name and address) appoint as my representative to act on my behalf to give, withhold or withdraw informed consent to health care decisions in the event that I am not able to do so myself.. The person I choose as my representative is: (Insert the name, address, area code and telephone number of the person you wish to designate as your representative) The person I choose as my successor representative is: If my representative is unable, unwilling or disqualified to serve, then I appoint (Insert the name, address, area code and telephone number of the person you wish to designate as your successor representative) This appointment shall extend to, but not be limited to, health care decisions relating to medical treatment, surgical treatment, nursing care, medication, hospitalization, care and treatment in a nursing home or other facility, and home health care..
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