Wyoming Medical Power of Attorney
This Medical Power of Attorney is created in accordance with the laws of the State of Wyoming. It allows you to designate an individual to make healthcare decisions on your behalf if you are unable to do so.
Principal's Information:
Name: _____________________________________
Address: ___________________________________
City, State, Zip: _____________________________
Date of Birth: _______________________________
Agent's Information:
Name: _____________________________________
Address: ___________________________________
City, State, Zip: _____________________________
Phone Number: _______________________________
Health Care Decisions:
I hereby grant my agent the authority to make decisions regarding my medical treatment and care. This includes, but is not limited to:
- Making choices about medical procedures and treatments.
- Accessing my medical records and information.
- Choosing healthcare providers and facilities.
- Consenting to or refusing treatment on my behalf.
- Making end-of-life decisions, if necessary.
This power is effective when I am unable to communicate my wishes regarding medical treatment.
Limitations:
Any specific limitations on the authority granted to my agent are as follows:
_____________________________________________________________________
_____________________________________________________________________
Signature:
______________________________
Date: _________________________
Witness Statement:
This document was signed in my presence by the principal.
Witness Name: ______________________________
Witness Address: ____________________________
Witness Signature: __________________________
Date: _____________________________________
Notary Acknowledgment:
State of Wyoming
County of ____________________________
Subscribed and sworn before me this ___ day of __________, 20__.
Notary Public: __________________________________
My commission expires: ____________________________