Virginia Living Will and Durable Power of Attorney Form

Virginia Living Will and Durable Power of Attorney Form has guidelines to assign someone as a Health Care Agent when the person signing the power of attorney is unable to take own health care decisions due to various unforeseen conditions. The power of attorney grants the right to the Health Care Agent to take action on the behalf of the person in his/her best interest.

Writing the name of the person, last four digits of SSN, date, and signing with the initial is necessary on each page of the power of attorney. Notarization of the document is not compulsory for its effectiveness, however; it has space for it. The power of attorney follows the directives by the Department of Veterans Affairs. A person granting the power of attorney describes the name of the person/s to take decisions on behalf, mode and type of treatment, and preferences for medical care, long-term care, mental health care, or any other types of health care required.

How to Fill the Virginia Living Will and Durable Power of Attorney Form

Write Name, last 4 digits of SSN, Street Address, City, State, and Zip along with home, work, and mobile phone numbers with area code in Part I: Personal Information.

Select between choices and sign with initials in Part II: Durable Power Of Attorney For Health Care to appoint a Health Care Agent. Write name of the person, his/her relation with you, address, zip code; and home, work, and mobile phone numbers with area code. You can designate an Alternate Health Care Agent by writing the name, relationship with you, address, and phone numbers in the space provided in B – Alternate Health Care Agent subsection.

Part III: Living Will requires input of life-sustaining treatment preferences. Select one option from all six conditions and among three choices each. Mark your preference with initials only in one box per condition. Write preferences for mental health and care if any, in space available in B – Mental Health Preferences subsection. Leave blank if you do not want to discuss or instruct. Write other preferences you feel necessary and are not covered anywhere in the document in the space available in C – Additional Preferences. You can attach more pages if necessary; however, mark your initials and date on every page and refer these pages in the space.

Mention your choice of affirmative adherence to the guidelines set out in the power of attorney by signing with initials in the appropriate space in D – How Strictly You Want Your Preferences Followed section.

Part IV: Signatures require your signature and date in A – Your Signature subsection. Ask two witnesses to sign and write the date, typed or printed name, Street Address, City, State, and Zip in the respective spaces available. Fill in the details for the second witness just as the first witness.

Part V: Signature And Seal Of Notary Public is optional and the Notary Public fills in the details in this subsection of the power of attorney for health care and living will.

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Virginia Living Will and Durable Power of Attorney Form