APPENDIX C: Advance Directives Forms

If you are interested in having a Medical Power of Attorney or a Living Will: 

  • You may obtain statutory forms from your health care provider.
  • The forms are also available online at WVU’s Center for End of Life at
  • You and two witnesses (not your relatives) sign and date the forms in front of a notary.

To revoke either a Medical Power of Attorney or a Living Will you may use the revocation forms that follow. 

  • Date the form
  • For Revocation of Medical Power of Attorney be sure to write in the name of the person you had chosen to be your agent
  • Sign your name and print your name
  • Give the revocation form or forms to your physician immediately

For more information see the West Virginia Center for End of Life Care on the web at or by phone 1 (877) 209-8086. 

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Dated: ___________________, ________ 

I hereby revoke the Medical Power of Attorney in which I named ______________________________________________________ as my agent, effective immediately upon receipt of this instrument by my attending physician. My attending physician shall please record this revocation in my medical record upon receipt of this instrument. 


(sign name) 


(print name) 


Dated:____________, _______ 

I hereby revoke my living will, effective immediately upon delivery of this instrument to my attending physician. My attending physician shall please record this revocation in my medical record upon receipt of this instrument. 


(sign name) 


(print name)



APPENDIX A:How to File A Consumer Complaint

(Taken from:, last visited June 15, 2015) 

If you have a complaint about a product or service and have been unable to resolve the dispute yourself, you may file a complaint with the Consumer Protection Division of The West Virginia Office of the Attorney General.

(A) Complete all pages of the attached consumer complaint form, use additional paper if necessary. Answer all questions fully, correctly, and truthfully. Please print clearly in ink or type.  

(B) Please send COPIES – front and back – of all documents or other papers that may relate to your complaint. DO NOT SEND ORIGINALS. Examples of papers you should copy and send are: contracts, financial disclosure statements, payment receipts, credit card receipts or statements, canceled checks, sales slips, order blanks, warranties, repair records or estimates, letters between you and the business, and any papers you have signed. 

(C) When describing your complaint, please explain all the important events in the order in which they occurred. Please provide dates whenever possible. Tell us the facts about your complaint rather than your feelings about what happened. If you need additional space to tell what happened, please continue on a separate page and attach it to your complaint. 

(D) Return or mail the completed Consumer Complaint form and copies of your papers to: 

Office of the Attorney General 

Consumer Protection Division 

P.O. Box 1789 

Charleston, WV 25326-1789 

(E) If you have any further questions about how to file your complaint, 

Toll free: 1 (800) 368-8808 

Telephone: 1 (304) 558-8986  


Find us on the web at:

APPENDIX B: Filing Complaints with State Licensing Authorities

Anyone may file a complaint with regard to licensed practitioners in West Virginia. Below is a list of state licensing authorities that consumers may contact with inquiries and complaints. Each individual licensing authority may have its own specific procedure for filing a complaint. You will likely be asked to send copies of all documentation, names of alleged violators, and your name and address.

List of State Licensing Authorities