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 www.wvendoflife.org.
- 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 www.wvendoflife.org or by phone 1 (877) 209-8086.
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REVOCATION OF MEDICAL POWER OF ATTORNEY
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.
REVOCATION OF LIVING WILL
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.