Mississippi Power of Attorney for Health Care
In the case of the principal wanting to give power to the agent to make health-related decisions on his behalf in the State of Mississippi, the following form has to be completed and submitted.
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Mississippi Advance Health-Care Directive
Explanation
You have the right to give instructions about your own health care. You also have the
right to name someone else to make health-care decisions for you. This form lets you do
either or both of these things. It also lets you express your wishes regarding the
designation of your primary physician. If you use this form, you may complete or modify
all or any part of it. You are free to use a different form.
Part 1 of this form is a power of attorney for health care. Part 1 lets you name another
individual as agent to make health-care 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 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 long-term health-care institution at which you are receiving care.
Unless the form you sign limits the authority of your agent, your agent may make all
health-care 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 health-care 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:
(a) Consent or refuse consent to any care, treatment, service, or procedure to
maintain, diagnose, or otherwise affect a physical or mental condition;
(b) Select or discharge health-care providers and institutions;
(c) Approve or disapprove diagnostic tests, surgical procedures, programs of
medication, and orders not to resuscitate; and
(d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration
and all other forms of health care.
Part 2 of this form lets you give specific instructions about any aspect of your health
care. 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 provided
for you to add to the choices you have made or for you to write out any additional
wishes.
Part 3 of this form lets you designate a physician to have primary responsibility for
your health care.
After completing this form, sign and date the form at the end and have the form
witnessed by one of the two alternative methods listed below. Give a copy of the signed
and completed form to your physician, to any other health-care providers you may have,
to any health-care institution at which you are receiving care, and to any health-care
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 health-care directive or replace this form at
any time.
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PART 1
PART I
POWER OF ATTORNEY FOR HEALTH CARE
(1) DESIGNATION OF AGENT: I designate the following individual as my agent to make
health-care decisions for me:
______________________________________________________________________
(name of individual you choose as agent)
______________________________________________________________________
(address) (city) (state) (zip code)
________________________________________________________________________________________________
(home phone) (work phone)
OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably
available to make a health-care decision for me, I designate as my first alternate agent:
________________________________________________________________________
(name of individual you choose as first alternate agent)
________________________________________________________________________
(address) (city) (state) (zip code)
________________________________________________________________________
(home phone) (work phone)
OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing,
able, or reasonably available to make a health-care decision for me, I designate as my second
alternate agent:
________________________________________________________________________
(name of individual you choose as first alternate agent)
________________________________________________________________________
(address) (city) (state) (zip code)
________________________________________________________________________
(home phone) (work phone)
The material contained in this document is provided by the statutes of the State of Mississippi in
the MS Code 1972 Annotated. This document is being provided as a service and does not
constitute legal advice. We make no claim as to the accuracy or completeness of the information
contained in this document. The information contained herein is not a substitute for professional
legal counsel.
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(2) AGENT'S AUTHORITY: My agent is authorized to make all health-care decisions for me,
including decisions to provide, withhold, or withdraw artificial nutrition and hydration, and all other
forms of health care to keep me alive, except as I state here:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(Add additional sheets if needed.)
(3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE:
My agent's authority
becomes effective when my primary physician determines that I am unable to make my
own health-care decisions unless I mark the following box. If I mark this box [ ], my
agent's authority to make health-care decisions for me takes effect immediately.
(4) AGENT'S OBLIGATION:
My agent shall make health-care decisions for me in
accordance with this power of attorney for health care, any instructions I give in Part 2 of
this form, and my other wishes to the extent known to my agent. To the extent my
wishes are unknown, my agent shall make health-care decisions for me in accordance
with what my agent determines to be in my best interest. In determining my best interest,
my agent shall consider my personal values to the extent known to my agent.
(5) NOMINATION OF GUARDIAN:
If a guardian of my person needs to be appointed
for me by a court, I nominate the agent designated in this form. If that agent is not
willing, able, or reasonably available to act as guardian, I nominate the alternate agents
whom I have named, in the order designated.
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PART 2
INSTRUCTIONS FOR HEALTH CARE
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f you are satisfied to allow your agent to determine what is best for you in making
end-of-life decisions, you need not fill out this part of the form. If you do fill out this part of
the form, you may strike any wording you do not want.
(6) END-OF-LIFE DECISIONS:
I direct that my health-care providers and others
involved in my care provide, withhold or withdraw treatment in accordance with the
choice I have marked below:
[ ] (a) Choice Not To Prolong Life
I do not want my life to be prolonged if (i) I have an incurable and irreversible condition
that will result in my death within a relatively short time, (ii) I become unconscious and,
to a reasonable degree of medical certainty, I will not regain consciousness, or (iii) the
likely risks and burdens of treatment would outweigh the expected benefits, or
[ ] (b) Choice To Prolong Life
I want my life to be prolonged as long as possible within the limits of generally
accepted health-care standards.
(7) ARTIFICIAL NUTRITION AND HYDRATION:
Artificial nutrition and hydration
must be provided, withheld or withdrawn in accordance with the choice I have made in
paragraph (6) unless I mark the following box. If I mark this box [ ], artificial nutrition and
hydration must be provided regardless of my condition and regardless of the choice I
have made in paragraph (6).
(8) RELIEF FROM PAIN:
Except as I state in the following space, I direct that
treatment for alleviation of pain or discomfort be provided at all
times, even if it hastens my death: __________________________________________
________________________________________________________________________
(9) OTHER WISHES:
(If you do not agree with any of the optional choices above and
wish to write your own, or if you wish to add to the instructions you have given above,
you may do so here.) I direct that:
________________________________________________________________________
________________________________________________________________________
(Add additional sheets if needed.)
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PART 3
PRIMARY PHYSICIAN
OPTIONAL
(10) I designate the following physician as my primary physician:
________________________________________________________________________
(name of physician)
_________________________________________________________________________________________________
(address) (city) (state) (zip code)
_____________________
(phone)
OPTIONAL: If the physician I have designated above is not willing, able, or
reasonably available to act as my primary physician, I designate the following physician
as my primary physician:
________________________________________________________________________
(name of physician)
_________________________________________________________________________________________________________
(address) (city) (state) (zip code)
_________________________
(phone)
(11) EFFECT OF COPY:
A copy of this form has the same effect as the original.
(12) SIGNATURES:
Sign and date the form here:
____________________________ ___________________________
(date) (sign your name)
____________________________ ___________________________
(address) (print your name)
____________________________
(city) (state)
(13) WITNESSES:
This power of attorney will not be valid for making health-care
decisions unless it is either (a) signed by two (2) qualified adult witnesses who are
personally known to you and who are present when you sign or acknowledge your
signature; or (b) acknowledged before a notary public in the state.
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ALTERNATIVE NO. 1
Witness
I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code of
1972, that the principal is personally known to me, that the principal signed or
acknowledged this power of attorney in my presence, that the principal appears to be of
sound mind and under no duress, fraud or undue influence, that I am not the person
appointed as agent by this document, and that I am not a health-care provider, nor an
employee of a health-care provider or facility. I am not related to the principal by blood,
marriage or adoption, and to the best of my knowledge, I am not entitled to any part of
the estate of the principal upon the death of the principal under a will now existing or by
operation of law.
___________________________ ____________________________
(date) (signature of witness)
_________________________________________ _________________________________________
(address) (printed name of witness)
_________________________________________
(city) (state)
Witness
I declare under penalty of perjury pursuant to Section 97-9-61, Mississippi Code of
1972, that the principal is personally known to me, that the principal signed or
acknowledged this power of attorney in my presence, that the principal appears to be of
sound mind and under no duress, fraud or undue influence, that I am not the person
appointed as agent by this document, and that I am not a health-care provider, nor an
employee of a health-care provider or facility.
________________________________ ___________________________
(date) (signature of witness)
___________________________________________ ____________________________________
(address) (printed name of witness)
___________________________________________
(city) (state)
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ALTERNATIVE NO. 2
State of __________
County of __________
On this ________ day of ________, in the year ________, before me,
___________________________ appeared ___________________________
personally known to me (or proved to me on the basis of satisfactory evidence) to
be the person whose name is subscribed to this instrument, and acknowledged
that he or she executed it. I declare under the penalty of perjury that the person
whose name is subscribed to this instrument appears to be of sound mind and
under no duress, fraud or undue influence.
Notary Seal
____________________________
(Signature of Notary Public)
My commission expires: __________________
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