Blank Wyoming Medical Power of Attorney Form

Wyoming Medical Power of Attorney

This document grants authority to a designated individual (referred to as the "Agent") to make health care decisions on behalf of the undersigned (referred to as the "Principal"), in accordance with the Wyoming Health Care Decisions Act.

Please complete all sections to ensure this document accurately reflects your wishes.

Principal's Information:

Name: ________________________________________

Address: ______________________________________

City: ______________________ State: WY Zip: _________

Date of Birth: _______________ Phone: _________________

Agent's Information:

Name: ________________________________________

Address: ______________________________________

City: ______________________ State: WY Zip: _________

Date of Birth: _______________ Phone: _________________

In designation of my Agent, I authorize them to make all forms of health care decisions on my behalf that I could make if I were capable, including the power to consent, to refuse consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. This power is subject to any statement of desires and special provisions that follow:

Special Provisions and Limitations:

(Specify any particular desires, limitations, or special provisions you wish to place on your Agent's authority to make decisions for you. If none, state "None".)

______________________________________________________________________________

______________________________________________________________________________

Alternative Agent:

In the event that my primary Agent is unable, unwilling, or ineligible to act as my Agent, I designate the following person as my alternative Agent:

Name: ________________________________________

Address: ______________________________________

City: ______________________ State: WY Zip: _________

Date of Birth: _______________ Phone: _________________

Effective Date and Duration:

This Medical Power of Attorney becomes effective immediately and remains in effect indefinitely unless I specify an expiration date or condition upon which this power will terminate:

Expiration Date/Condition: ____________________________________________________

Signature and Acknowledgment:

By signing below, I affirm that I understand the contents of this document and the authority I am granting to my Agent. I am of sound mind and under no duress or undue influence at the time of this designation.

Principal's Signature: ___________________________ Date: _____________

State of Wyoming
County of _______________

This document was acknowledged before me on (date) __________ by (name of principal) _________________.

Notary Public Signature: ________________________

My commission expires: _______________

Witnesses:

(The Wyoming Health Care Decisions Act requires that this document be witnessed by two individuals who are not the appointed agent, not related to you by blood, marriage, or adoption, and not entitled to any portion of your estate.)

Witness 1 Signature: ___________________________ Date: _____________

Name: ________________________________________

Witness 2 Signature: ___________________________ Date: _____________

Name: ________________________________________

Statement by Witnesses:

We declare that the Principal appears to be of sound mind and free from duress at the time this document was signed, and that we, in the Principal's presence, sign our names as witnesses.