 | Virginia Medical Power of Attorney Form |
The Virginia medical power of attorney form is a legal document that is available to a Principal so that they may record in writing, their health care wishes should the time come that they are no longer able to communicate their decisions on their own. This form will also allow the Principal to appoint an Agent to make their decisions on their behalf. Once completed the document must be witnessed and acknowledged to be effective. The document may be revoked at the discretion of the Principal, in writing and by delivery to the Agent.
How to Write
Step 1 – Download the Document –
- Review the introduction
Step 2 – Principal’s Information – Enter the following:
- Full name
- Last four digits of the Social Security Number (SSN)
- Street Address
- City, State and Zip Code
- Home phone
- Work phone
- Cell phone
- Review the Privacy Act Information
Step 3 – Establishment of Principal’s Directives – Submit:
- Principal’s full name
- Last four digits of Social Security Number (SSN)
- Review the information in Part II before proceeding
Step 4 – Appointment of Agent –
- Principal must initial their selection
- If appointing an Agent – Enter the following:
- Agent’s full name
- Relationship to Principal
- Agent’s street address
- City, State and Zip Code
- Home phone
- Work phone
- Cell phone
Step 5 – Alternate Agent – Enter the Principal’s information and continue – Enter:
- Alternate Agent’s full name
- Relationship to Principal
- Alternate’s street address
- City, State and Zip Code
- Home phone
- Work phone
- Cell phone
Step 6 – Specific Preferences For Life Sustaining Treatments –
- Review the information contained within the introduction of this section
- In the table provided, consider the scenarios and initial the selection that indicates your wishes
Step 7 – Mental Health Preferences –
- Review the information at the top of this section
- Submit any of the information you would like to have available to your Agent, family and health care providers
Step 8 – Additional Preferences –
- Read the information at the top of this section
- This section is optional – If the Principal would elect to provide additional information, enter it into the space provided
- Should more space be required, add sheets and attach to these pages
- Enter the initials of the Principal, preceding the box, that would best indicate how closely the preferences should be followed
Step 9 – Signatures –
- Signature of Principal
- Date of signature in mm/dd/yyyy format
- Witnesses must read and agree to witness statements and enter:
- Witnesses signatures
- Date of signatures in mm/dd/yyyy format
- Printed/Typed full name
- Street address
- City, State and Zip Code
- Notary Acknowledgement and seal
