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Wyoming Advance Healthcare Directive Form

All adults can benefit from thinking about what their healthcare choices would be if they are unable to speak for themselves. It’s not an easy conversation to have, but your decisions can be written in a document called an advance directive so others know what they are.

You have the right to give instructions about your own healthcare. You also have the right to name someone else to make healthcare decisions for you. The Advance Healthcare Directive form lets you do either or both of these things.

If you use the Advance Healthcare Directive form, you may choose whether to complete all or any part of it or you may modify all or any part of it. You also are free to use a different form, but please note that certain provisions must be included in the form for it to be a legal document in Wyoming.

Download the Advance Directive Form


Directions

Part 1

The first section of this form is a Power of Attorney for Healthcare. This lets you name another individual as agent to make healthcare decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable.

You also may name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator or employee of a residential or community care facility at which you are receiving care.

Unless the form you sign limits the authority of your agent, your agent may make all healthcare decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all healthcare decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to:

  • Consent or refuse consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition;
  • Select or discharge healthcare providers and institutions;
  • Approve or disapprove diagnostic tests, surgical procedures, medication and orders not to resuscitate;
  • Direct the provision, withholding or withdrawal of artificial nutrition and hydration and all other forms of healthcare.

Part 2

The second section of this form lets you give specific instruction about any aspect of your healthcare. Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes.

After completing this form, sign and date the form at the end. This form must either be signed before a notary public or, in the alternative be witnessed by two (2) witness.

Give a copy of the signed and completed form to your physician, to any other healthcare providers you may have, to any healthcare institution at which you are receiving care and to any healthcare agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility.

You have the right to revoke this advance healthcare directive or replace this form at any time.