Wyoming Advance Health Care Directive(Living Will) Form

The Wyoming advance health care directive(living will) is a document that is designed to guide a person (principal) through the process of outlining the medical preference to be observed by physicians and health care agent(s) when the principal is no longer able to communicate their choices to their medical team. The document will immediately provide the ability to appoint a health care agent. This agent will be responsible to ensure that all of the principal’s wishes are implemented as stated by the principal in written word within their document. This document must be completed while the is of sound mind. The document may also be revoked or changed at any time that the principal chooses.

Laws – 35-22-101 et seq. Living Will

How to Write

Step 1 – Download the form –

  • Submit the full name of the Principal on the top of the first page of the document

Step 2 – At the top of each page:

  • Print the full name of the principal
  • The Date of the document in mm/dd/yyyy format
  • The Principal must provide the initial, once the document is complete, stating that the Principal has, in fact completed each individual page

Step 3 – Power of Attorney for Health Care – Designation of Agent – This is optional- If the Principal would like to use this form to designate their agent, provide the following information:

  • Agent’s full name
  • Address
  • City, State, Zip Code
  • Home phone
  • Work phone
  • Cell phone

In the event the primary agent is no longer able to serve or the principal decides to revoke authority, the principal may designate an alternate agent – enter the following:

  • Name of alternate agent
  • Address
  • City, State, Zip Code
  • Home phone
  • Work phone
  • Cell phone

Step 3 – Agent’s Authority –

  • The principal must read the statement and add any exception in the lines provided
  • The Principal must review the statement regarding when the document would become effective and select one of the options provided
  • Principal must read the statement regarding the Agent’s obligations

Step 4 – End of Life Decisions –

  • The principal must carefully review the statement in this section, then check and initial the selection that best reflects their personal wishes
  • With regard to nutrition and hydration – the principal must read the statement, then check and initial only one of the choices available
  • Regarding pain relief – the principal must carefully read the statement, then check and initial the best option for them.
  • If the principal would like to express any other wishes, enter them on the lines provided. If more space is required, add a sheet and attach it to the document

Step 5 – Donation of Organs and Tissues Upon Death –

  • Check and initial only one of the choices provided

Step 6 – Information About Health Care Provider – The principal must provide information regarding their health care provider as follows:

  • Name of Physicisan
  • Address
  • City, State, Zip Code
  • Telephone number

If more information is needed about the principal’s health care it may be obtained by contacting:

  • Provide the name of the health care institution or hospice
  • Address
  • City, State, Zip Code
  • Telephone number

Step 7 – Signatures, Witnesses OR Notarization – The Principal may choose to use either 2 witnesses OR a notary public – begin by providing the following:

  • The Principal’s printed name
  • Signature
  • Date of signature
  • Address
  • City, State and Zip Code

Witnesses – Once the witnesses have witnessed the signature of the principal, they must enter:

  • Witnesses printed names
  • Addresses
  • Witnesses signatures
  • Date of signatures in mm/dd/yyyy format

OR – If the Principal prefers to use a notary as their witness:

  • The principal must sign the document before a notary public
  • The notary will complete the acknowledgement by completing the notary section of the document and by affixing their seal or stamp

 

 

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