WYOMING DURABLE HEALTHCARE POWER OF ATTORNEY
(a/k/a “Advance Health-Care Directive”)
[// GUIDANCE: This template is drafted to comply with the Wyoming Health Care Decisions Act, Wyo. Stat. Ann. § 35-22-401 et seq., and incorporates a HIPAA release compliant with 45 C.F.R. §§ 160 & 164. Customize bracketed text and review final form for client-specific facts before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Appointment of Healthcare Agent
- Scope of Authority
- End-of-Life Decisions
- HIPAA Authorization
- Nomination of Guardian
- Agent Standards of Conduct
- Indemnification & Limitation of Liability
- Reliance & Third-Party Protections
- Revocation & Termination
- Governing Law; Forum Selection; Injunctive Relief
- Miscellaneous Provisions
- Execution & Attestation
1. DOCUMENT HEADER
1.1 Title. Durable Healthcare Power of Attorney and Advance Health-Care Directive (“Agreement”).
1.2 Parties.
a. “Principal”: [PRINCIPAL LEGAL NAME], a resident of the State of Wyoming, with a primary residence at [ADDRESS].
b. “Agent”: [AGENT LEGAL NAME], residing at [ADDRESS].
c. “Alternate Agent(s)”: (i) [FIRST ALTERNATE]; (ii) [SECOND ALTERNATE] (collectively, “Alternate Agent(s)”).
1.3 Effective Date. This Agreement becomes effective immediately upon execution (“Effective Date”) and remains in force until revoked pursuant to Section 11.
1.4 Consideration. The parties acknowledge mutual promises and the Principal’s intent to create enforceable agency powers for healthcare decisions.
1.5 Governing Statute. Wyo. Stat. Ann. § 35-22-401 et seq. governs this instrument unless superseded by applicable federal law.
2. DEFINITIONS
“Advance Directive” means this instrument, including any living-will instructions contained herein.
“Agent” means the person designated in Section 1.2(b) with the authority granted in this Agreement.
“End-Stage Condition” has the meaning set forth in Wyo. Stat. Ann. § 35-22-403(a)(x).
“HIPAA” means the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations at 45 C.F.R. parts 160 & 164.
“Incapacity” means the inability to understand the significant benefits, risks, and alternatives to proposed healthcare and to make and communicate a healthcare decision, as certified pursuant to Wyo. Stat. Ann. § 35-22-403(a)(xi).
“Principal” means the individual executing this Agreement as set forth in Section 1.2(a).
“State Probate Court” means the district court sitting in probate jurisdiction for the county in which the Principal resides at the time an action is commenced.
3. APPOINTMENT OF HEALTHCARE AGENT
3.1 Designation. The Principal hereby appoints the Agent to act on the Principal’s behalf for all healthcare decisions as permitted by law.
3.2 Successor Appointment. If the Agent is unwilling, unable, or unavailable to act, each Alternate Agent shall serve, in the listed order, with the same powers herein granted.
3.3 Durable Nature. This appointment is durable and shall not be affected by the Principal’s subsequent incapacity or disability.
4. SCOPE OF AUTHORITY
4.1 General Powers. Subject to Sections 4.2-4.6, the Agent may make any and all healthcare decisions the Principal could make if capable, including without limitation:
a. Consent, refuse, or withdraw consent to medical treatment;
b. Select and discharge healthcare providers and facilities;
c. Access and transfer medical records;
d. Authorize pain management and palliative care;
e. Make anatomical gift decisions pursuant to applicable law.
4.2 Limitations. The Agent’s authority is limited as follows: [INSERT ANY LIMITATIONS OR “None.”].
4.3 Mental Health Treatment. The Agent is [AUTHORIZED / NOT AUTHORIZED] to consent to or refuse psychotropic medications, electro-convulsive therapy, and admission to a mental health facility.
4.4 Life-Sustaining Treatment. See Section 5.
4.5 Autopsy & Disposition. The Agent is authorized to (i) request an autopsy; (ii) determine funeral arrangements; and (iii) control disposition of remains, unless the Principal has executed a separate disposition directive.
4.6 Delegation. The Agent may not delegate the granted powers except to an Alternate Agent pursuant to Section 3.2.
5. END-OF-LIFE DECISIONS
5.1 Statement of Intent. The Principal’s wishes stated herein are to be honored, and the Agent shall implement them in good faith.
5.2 Terminal Condition or Persistent Vegetative State. If certified by two (2) licensed physicians (one being the attending physician), the following expresses the Principal’s intent (select one):
☐ Directive A – WITHHOLD OR WITHDRAW life-sustaining treatment, including artificial nutrition and hydration, if such treatment merely prolongs the dying process.
☐ Directive B – CONTINUE life-sustaining treatment, including artificial nutrition and hydration, regardless of medical prognosis.
☐ Directive C – FOLLOW AGENT’S DISCRETION subject to medically appropriate care.
5.3 Pain Relief. The Principal desires adequate pain management even if such care may hasten death as a secondary effect.
5.4 Pregnancy. If the Principal is pregnant and it is likely the fetus could develop to live birth, the Principal’s end-of-life directives shall [REMAIN / NOT REMAIN] in effect.
[// GUIDANCE: Wyoming law does not impose a mandatory pregnancy limitation; practitioners should confirm client intent.]
6. HIPAA AUTHORIZATION
6.1 Authorization. The Principal authorizes any “covered entity” or “business associate” (as defined by HIPAA) to disclose the Principal’s protected health information (“PHI”) to the Agent and Alternate Agent(s) for purposes of healthcare decision-making.
6.2 Expiration. This authorization shall remain valid until revoked under Section 11 or for fifty (50) years after the Principal’s death, whichever is earlier.
6.3 Redisclosure. The Agent may redisclose PHI as necessary to carry out authorized duties, understanding that redisclosed information may no longer be protected by HIPAA.
7. NOMINATION OF GUARDIAN
7.1 Preference. Should a court determine that appointment of a guardian is necessary, the Principal nominates the Agent as first choice and the Alternate Agent(s) in the order named above as successors.
7.2 Court Discretion. The court retains discretion to appoint a qualified person; however, the Principal requests deference to this nomination.
8. AGENT STANDARDS OF CONDUCT
8.1 Fiduciary Duty. The Agent shall act (i) in good faith; (ii) consistent with the Principal’s known wishes; and (iii) in the Principal’s best interest if wishes are unknown.
8.2 Consultation. The Agent shall confer with appropriate medical personnel, family members, and spiritual advisors, as the Agent deems optimal, while remaining guided by the Principal’s expressed preferences.
8.3 Recordkeeping. The Agent shall maintain contemporaneous records of significant healthcare decisions made on behalf of the Principal.
9. INDEMNIFICATION & LIMITATION OF LIABILITY
9.1 Good-Faith Protection. The Principal agrees to indemnify and hold harmless the Agent and Alternate Agent(s) from any liability, claim, or expense that arises from actions taken in good faith pursuant to this Agreement, except for willful misconduct or gross negligence.
9.2 Liability Cap. Under no circumstances shall the Agent’s personal liability exceed the extent of insurance or indemnification provided herein for acts or omissions undertaken in good faith.
10. RELIANCE & THIRD-PARTY PROTECTIONS
10.1 Reliance. Any healthcare provider or third party may rely on a copy of this Agreement and on any representation by the Agent regarding its current validity.
10.2 No Duty to Investigate. A healthcare provider who acts in reliance on this Agreement in good faith is protected to the fullest extent permitted by Wyo. Stat. Ann. § 35-22-407.
11. REVOCATION & TERMINATION
11.1 Revocation by Principal. The Principal may revoke this Agreement at any time by:
a. A written, signed, and dated instrument;
b. An oral expression of intent to revoke in the presence of two (2) witnesses; or
c. Physical destruction of the original instrument by the Principal or at the Principal’s direction.
11.2 Automatic Termination. This Agreement terminates upon the Principal’s death except as to authority granted in Sections 4.5 and 6 (anatomical gifts, disposition of remains, and PHI access).
11.3 Divorce. If the Agent is the Principal’s spouse, appointment is revoked upon entry of a final decree of divorce or dissolution unless the Principal affirmatively re-appoints the Agent thereafter.
12. GOVERNING LAW; FORUM SELECTION; INJUNCTIVE RELIEF
12.1 Governing Law. This Agreement shall be governed by and construed in accordance with the healthcare laws of the State of Wyoming, without regard to conflict-of-laws principles.
12.2 Forum Selection. Any action seeking interpretation, enforcement, or injunctive relief concerning this Agreement shall be brought exclusively in the State Probate Court.
12.3 Injunctive Relief. The Agent, Principal, and any interested person may seek injunctive or declaratory relief to enforce the healthcare directives herein, without prejudice to other remedies.
13. MISCELLANEOUS PROVISIONS
13.1 Severability. If any provision is held invalid, the remaining provisions shall remain in full force and effect consistent with the Principal’s intent.
13.2 Amendment. The Principal may amend this Agreement only by a duly executed written instrument referencing this Section 13.2.
13.3 Integration. This Agreement embodies the entire healthcare agency and advance directive of the Principal and supersedes all prior oral or written directives regarding the same subject matter.
13.4 Copies. Photographic or electronic copies of this fully executed Agreement shall have the same force and effect as the original.
13.5 Electronic Signatures. To the maximum extent permitted by Wyo. Stat. Ann. § 40-21-101 et seq. (Uniform Electronic Transactions Act), electronic signatures shall be deemed originals.
14. EXECUTION & ATTESTATION
[// GUIDANCE: Wyoming law permits EITHER (a) two adult witnesses OR (b) notarization. The Agent or immediate family members may NOT serve as witnesses. Include one method only.]
14.1 Principal Signature
I, [PRINCIPAL LEGAL NAME], execute this Durable Healthcare Power of Attorney and Advance Health-Care Directive on the Effective Date.
[PRINCIPAL LEGAL NAME], Principal
Date: _______
OPTION A – NOTARIZATION
State of Wyoming )
County of [___] ) ss.
On this _ day of __, 20____, before me, the undersigned Notarial Officer, personally appeared [PRINCIPAL LEGAL NAME], known to me or satisfactorily proven to be the person whose name appears above, who acknowledged that he/she executed the same for the purposes therein contained.
Witness my hand and official seal.
Notarial Officer
My commission expires: _______
(Seal)
OPTION B – TWO WITNESSES
We declare under penalty of perjury under the laws of the State of Wyoming that the Principal is personally known to us, appeared to be of sound mind, and signed or acknowledged this instrument in our presence. We are at least eighteen (18) years of age, not related to the Principal by blood, marriage, or adoption, not entitled to any portion of the Principal’s estate, and not directly financially responsible for the Principal’s medical care.
Witness #1:
Name: _____
Address: _____
Date: _______
Witness #2:
Name: _____
Address: _____
Date: _______
14.2 Agent Acknowledgment
I, [AGENT LEGAL NAME], accept my appointment as Agent under this Agreement and acknowledge my fiduciary duties under Wyoming law.
[AGENT LEGAL NAME], Agent
Date: _______
[Repeat acknowledgment blocks for each Alternate Agent, if desired.]
[// GUIDANCE: Provide executed copies to (i) the Agent, (ii) Alternate Agent(s), (iii) primary care physician, and (iv) any healthcare facility where the Principal receives regular treatment. Consider filing a copy with the county clerk for ease of access.]