Healthcare Proxy for Virginia

Healthcare Proxy for Virginia

Under Virginia State Law


This document will be valid after you and your witnesses sign it. However, your healthcare Agent and any alternates must receive a copy of this document and sign and date the section below titled Agent Acknowledgment and Acceptance in order to accept his or her responsibilities before making any decisions on your behalf.


I, _____________, the "Principal," appoint the following person as my healthcare "Agent" (which includes within its meaning a healthcare 'proxy,' 'surrogate,' 'representative,' 'executor,' or 'patient advocate' in jurisdictions that so require) to make healthcare decisions on my behalf and to have the authority specified herein. I have notified the Agent of my wishes concerning health care. I appoint the following individual as my healthcare Agent:

Agent: _____________

Relationship: _____________

Address: _____________
_____________, _____________ _____________

Phone Number: _____________

Agent's Authority. My Agent named herein is authorized to make any and all healthcare decisions for me, except as otherwise limited by this document. This is a durable power of attorney, and, as such, my Agent's authority will begin when I become incapacitated or am otherwise unable to make decisions for myself, as determined by a physician. My Agent's authority will continue until properly revoked or terminated in accordance herewith. Without limitation and unless otherwise stated herein, this authority shall include the authority to:

  1. authorize my admission to or discharge from any hospital, nursing care facility, or similar facility or service even against medical advice;
  2. authorize, or refuse to authorize, any medication or procedure intended to relieve pain, even though such use may lead to physical damage, addiction, or hasten the moment of, but not intentionally cause, my death;
  3. refuse, consent, or revoke consent to any and all types of medical care, treatments, surgical procedures, diagnostic procedures, medication, and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, nutrition and hydration, and cardiopulmonary resuscitation; and
  4. take any other action necessary for documenting and assuring implementation of my healthcare decisions, including, without limitation, granting any waiver or release from liability required by any hospital, physician, nursing care provider, or other healthcare provider; signing any documents relating to refusals of treatment or my leaving a facility against medical advice; and pursuing any legal action in my name, and at the expense of my estate, to force compliance with my wishes as determined by my Agent, or to seek actual or punitive damages for the failure to comply.

Unless my wishes on the subject are already known, I direct my Agent to attempt to consult with me to determine my wishes concerning any healthcare decision if I am able to communicate in any way, including the ability to blink. To the extent my wishes are unknown, my Agent shall make healthcare decisions for me in accordance with what he or she determines to be in my best interest. In determining my best interest, my Agent shall consider my personal values to the extent known to him or her and may consult any of my known friends and family members to help inform his or her judgment.

My Agent may accompany me in an ambulance or air ambulance if, in the opinion of the ambulance personnel, protocol permits a passenger, and my Agent may visit or consult with me in person while I am in a hospital, skilled nursing facility, hospice, or other healthcare facility or service if its protocol permits visitation.


____ I expressly authorize my Agent to direct the withholding or withdrawal of artificial nutrition or hydration and all other forms of health care to keep me alive. I do not want my life to be prolonged, nor do I want life-sustaining or death-delaying treatment to be provided or continued if my Agent believes the burdens of the treatment outweigh the expected benefits.

_____ I do not wish to be resuscitated in the event that my quality of life would be so impaired that I would be miserable or it would be a tremendous financial or emotional burden to my family or loved ones. In such a situation, I would only want to live if my Agent believes the expected benefit of the treatment outweighs the burden. Decisions concerning life support are to be made in consensus with any doctors or other healthcare professionals.

Medical Release and HIPAA Waiver of Confidentiality for My Agent (Optional)


____ I authorize my Agent to exercise all my rights regarding the use and disclosure of my individually identifiable health information or other medical records, including, without limitation, the following: (a) requesting, reviewing, and receiving any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, insurance, and financial and other information related to any past, present, or future physical or mental health condition, including information related to sexually transmitted diseases, HIV/AIDs, mental illness, and substance abuse; and (b) any written or oral opinions of my physician or healthcare provider concerning such information. My Agent may also execute on my behalf any releases or other documents that may be required in order to obtain this information and consent to the disclosure of this information. This medical release applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (a.k.a. HIPAA), 42 USC 1320d and 45 CFR 160-164.



Filling out this section is optional. If you so choose to fill out this section, initial only one of the following: (INITIAL ONE)

_____ I do not consent to an autopsy in any situation unless otherwise required by law.

_____ I consent to an autopsy.

_____ I authorize my Agent to decide whether I am to be autopsied.


You have the option of consulting a physician before initialing any choice in this document. If you do consult a physician, it is recommended that you have him or her complete this affidavit and give the physician a copy to keep.

I, Dr._____________________________, have reviewed this document with _____________ and have discussed his or her questions regarding the possible medical consequences of the medical choices provided herein. This discussion occurred on ______________ (date).

I agreed to comply with the provisions of this directive.

Physician's Signature: ____________________________________

Physician's Address: ____________________________________


Date: _______________________


Effective Date. This document will be effective when signed, and my Agent's authority to make healthcare decisions on my behalf will begin when I become incapacitated or am otherwise unable to make decisions for myself, as determined by a physician.


____ Except in the case of mental illness, my Agent's authority becomes effective when my primary physician determines that I am unable to make my own healthcare decisions. In the case of mental illness, my Agent's authority becomes effective when a court determines I am unable to make my own decisions, or, in an emergency, if my primary physician or another healthcare provider determines I am unable to make my own decisions.

Duration and Revocation. The authority of my Agent, when effective, shall not terminate or be void or voidable if I am or become disabled or in the event of later uncertainty as to whether I am dead or alive. I understand that this Power of Attorney exists indefinitely from the date I execute this document unless I revoke it or establish a shorter time or revoke the Power of Attorney. The authority I have granted my Agent continues to exist until the time I become able to make healthcare decisions for myself. Any time while I am competent, I may revoke this Power of Attorney in a writing I sign or by communicating my intent to revoke, in any clear and consistent manner, to my Agent or my healthcare provider. By executing this instrument I revoke any prior healthcare power of attorney.

Amendment. I retain the right to revoke or amend this Power of Attorney and to substitute other agents in place of my Agent. Amendments to this Power of Attorney must be made in writing by me personally. They must be attached to the original of this document and, if the original is recorded, must be recorded in the same county or counties as the original, although failure to record any amendment will not alter its affect.

Jurisdiction, Severability, and Durability. This instrument is intended to be valid in any jurisdiction in which it is presented. The powers delegated herein are severable, so that the invalidity of one or more powers or provisions shall not affect the validity of any others. This Power of Attorney shall not be affected or revoked by my incapacity or mental incompetence.

Reliance of Third Parties on Healthcare Agent. No person who relies in good faith upon the authority of or any representations by my Agent shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives for actions or omissions in reliance on that authority or those representations.

The powers conferred on my Agent by this document may be exercised by my Agent alone, and my Agent's signature or action taken under the authority granted in this document may be accepted by persons as fully authorized by me and with the same force and effect as if I were personally present, competent, and acting on my own behalf. All acts performed in good faith by my Agent pursuant to this Power of Attorney are done with my consent and shall have the same validity and effect as if I were present and exercised the powers myself, and shall inure to the benefit of and bind me, my estate, my heirs, successors, assigns, and personal representatives. The authority of my Agent pursuant to this Power of Attorney shall be superior to and binding upon my family, relatives, friends, and others.

Ratification. I ratify and confirm all that my Agent does or causes to be done under the authority granted in this instrument. All contracts, promissory notes, checks, or other bills of exchange, drafts, other obligations, instruments, and other documents signed, endorsed, drawn, accepted, made, executed, or delivered by my Agent will bind me, my estate, my heirs, successors, and assigns.

Signature of Agent. My Agent must use the following form when signing on my behalf pursuant to this Power of Attorney: [Principal Name] by [Agent Name], Agent.

Governing Law. This instrument is executed under and shall be construed according to the laws of Virginia.

Reliance on this Power of Attorney. Any person, including my Agent, may act in reliance upon the validity of this Power of Attorney or a copy of it unless that person knows it has terminated or is no longer valid.

Original Copy. The fully executed original copy of this Power of Attorney is in the possession of my Agent.

Acknowledgments. I have been provided with a disclosure statement explaining the effect of this document. I have read and understand the information contained in the disclosure statement.


  1. This Agent designation is not effective unless the Principal is unable to participate in decisions regarding the Principals medical or mental health, as applicable. If this Agent designation includes the authority to make an anatomical gift, the authority remains exercisable after the Principal's death.
  2. The Agent shall not exercise powers concerning the Principal's care, custody, and medical or mental health treatment that the Principal, if the Principal were able to participate in the decision, could not have exercised on his or her own behalf.
  3. This Agent designation cannot be used to make a medical treatment decision to withhold or withdraw treatment from a Principal who is pregnant if that would result in the pregnant Principal's death.
  4. The Agent may make a decision to withhold or withdraw treatment that would allow a Principal to die only if the Principal has expressed in a clear and convincing manner that the Agent is authorized to make such a decision, and that the Principal acknowledges that such a decision could or would allow the Principal's death.
  5. The Agent shall not receive compensation for the performance of his or her authority, rights, and responsibilities, but the Agent may be reimbursed for actual and necessary expenses incurred in the performance of his or her authority, rights, and responsibilities.
  6. The Agent shall act in accordance with the standards of care applicable to fiduciaries when acting for the Principal and shall act consistent with the Principal's best interests. The known desires of the Principal expressed or evidenced while the Principal is able to participate in medical or mental health treatment decisions are presumed to be in the Principal's best interests.
  7. The Principal may revoke his or her Agent designation at any time and in any manner sufficient to communicate intent to revoke.
  8. The Principal may waive his or her right to revoke the Agent designation as to the power to make mental health treatment decisions, and if such a waiver is made, his or her ability to revoke as to certain treatment will be delayed for 30 days after the Principal communicates his or her intent to revoke.
  9. The Agent may revoke his or her acceptance of the Agent designation at any time and in any manner sufficient to communicate intent to revoke.

Agent. I, _____________, understand the above terms, conditions, and responsibilities and am willing to serve as the healthcare Agent for the named Principal.

Signature: ________________________________________

Date: _________________________


I sign this healthcare power of attorney voluntarily. I understand the choices I have made, I am under no duress to sign this, and declare that I am emotionally and mentally competent at this time. I am signing this in the presence of a notary public and/or the appropriate number of witnesses as required by state law.

Your Name: _____________

Address: _____________
_____________, _____________ _____________

Phone Number(s): _____________

Date of Birth: _____________

SSN or TIN: __________________________

Your Signature: ____________________________________________________

Date Signed: __________________________


I AM WITNESSING THIS FORM UNDER PENALTY OF PERJURY AND SWEAR AS FOLLOWS: that the individual who signed or acknowledged this healthcare power of attorney is personally known to me, or that the individual's identity was proven to me by convincing evidence; that the individual signed or acknowledged this document in my presence; that I believe this person to be of sound mind and under no duress, fraud, or undue influence; that I did not sign the person's signature without consent; that I am not the healthcare Agent appointed in this document; that I am not the individual's attending physician, healthcare provider, an employee of the individual's healthcare provider, the operator of a community healthcare facility, the operator of a residential care facility for the elderly, a relative of an owner or operator of a healthcare facility in which the Principal is a patient or resident, nor an employee of an operator of a residential care facility for the elderly; that I am not related to the person by blood, adoption, or marriage and not entitled to any part of his or her estate under a currently existing will or by operation of law; and that I am at least 18 years of age and am not directly responsible for paying for his or her medical care.

Name of first witness: ___________________________________

Signature: _____________________________________________

Address of witness: _____________________________________


Date: _______________________

Name of second witness: _________________________________

Signature: _____________________________________________

Address of witness: _____________________________________


Date: _________________________

Note: If the Principal is physically unable to sign, each witness must also sign the following statement:

The Principal has directly indicated to me that this healthcare power of attorney expresses his or her wishes and that the Principal intends to adopt this document at this time.

Witness: ______________________________ Date: _____________

Witness: ______________________________ Date: _____________


State of Virginia
County of ____________________________

On _____________ (date), before me, _____________________________ (notary), appeared _____________, personally known to me (or proved to me on the basis of satisfactory evidence), and of sound mind and free from duress, to be the person(s) whose name(s) is/are subscribed to the within healthcare proxy and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or entity upon behalf of which the person(s) acted, executed the instrument. Furthermore, I am not the person the individual appointed as his or her Agent.

I certify under PENALTY OF PERJURY that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Print: ____________________________     Commission Expires: _______________

Sign: ____________________________      [Affix seal]

            NOTARY PUBLIC

Note: If the Principal is physically unable to sign, the notary must also sign the following statement:

The Principal has directly indicated to me that this healthcare power of attorney expresses his or her wishes and that the Principal intends to adopt this document at this time.

Notary: ______________________________ Date: _____________

Instructions for Your Healthcare Proxy

Use the LegalNature healthcare proxy to designate someone you trust to make important healthcare decisions on your behalf. It is important to have a healthcare proxy if you have been diagnosed with a serious illness. Even if you are still healthy now, it is smart to protect yourself in case something should happen to you.

In your state, this person may be called your agent, proxy, representative, or something similar. Your agent is legally required to follow your directions listed in the document as well as any other wishes you communicate to him or her. You can also use our living will form, which includes a healthcare power of attorney in it, to specify your wishes concerning treatment you receive when you become too sick to speak for yourself.

Your healthcare agent needs to be at least 18 years old and mentally competent to follow your directions. In addition, read your document for any additional state-specific requirements. Many states prevent you from appointing your physician or an employee of your healthcare provider as your agent. If you are unsure, it is best to appoint someone who does not fall into these categories and is someone you trust to carry out your wishes no matter what.

In addition, the LegalNature healthcare power of attorney allows you the option to appoint a guardian of your person or estate should you need one. You can also elect to designate your primary physician and your wishes concerning organ donation and burial.

Executing Your Healthcare Proxy

It is very important that you read the ENTIRE document before signing. Not only are you delegating important authority to your agent that you need to be aware of, but there are many places that require you to initial next to your choices. Initialing is required to both indicate your choice and to prove your wishes in the event there is ever a dispute. Once you are sure you have read the document and indicated your healthcare choices, simply sign and date where applicable and follow the witnessing requirements below.

Witnessing Requirements

In Virginia, at least two witnesses must sign. However, it is best (and we recommend) to have two disinterested witnesses AND a notary sign your power of attorney. This will help verify the authenticity of the document should there ever be a question.

Please note that the language you see here changes depending on your answers to the document questionnaire.

Healthcare Proxy

A healthcare proxy form allows you, the "principal," to appoint another person, called a "proxy," to make medical decisions on your behalf when you become too sick to do so. The proxy must abide by the principal's healthcare wishes and follow any specific limitations on the proxy's decision-making authority.

LegalNature's healthcare proxy form includes important optional features, such as appointing a guardian over the principal’s personal estate and naming a primary physician. The principal may even specify wishes concerning organ donation and funeral arrangements.

LegalNature's healthcare proxy form gives the principal and his or her loved ones the peace of mind that, when the time comes, the principal's healthcare wishes will be carried out exactly as desired.

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