Mississippi Medical Power of Attorney
This Medical Power of Attorney is a legal document that grants an individual (the “Agent”) the authority to make healthcare decisions on behalf of the person creating the document (the “Principal”), in accordance with the Mississippi Health Care Decisions Act. This authority comes into effect only when the Principal is unable to make decisions for themselves due to incapacity. It is a significant responsibility and should be granted after careful consideration.
To create a Mississippi Medical Power of Attorney, please provide the necessary information where blanks appear and review the document carefully before signing.
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I, _______________ [Your Full Legal Name], residing at _______________ [Your Full Address], being of sound mind, do hereby appoint:
Agent’s Name: _______________
Agent’s Address: _______________
Agent’s Telephone Number: _______________
as my Attorney-in-Fact (“Agent”) to make health care decisions for me as authorized in this document. 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.
[] My Agent’s authority to make health care decisions for me takes effect immediately and is not conditioned upon my lack of capacity to make health care decisions.
In the event the above-named Agent is unable, unwilling, or unavailable to act as my health care Agent, I hereby appoint the following person as my successor Agent:
Successor Agent’s Name: _______________
Successor Agent’s Address: _______________
Successor Agent’s Telephone Number: _______________
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Special Instructions: (Provide any specific limitations you wish to place on your Agent’s authority to make health care decisions for you, the type of treatments or health care you do or do not want, or any other wishes and preferences. If you have no specific instructions, you may leave this section blank.)
Instructions: ___________________________________________________________
_________________________________________________________________________
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This Medical Power of Attorney will remain in effect indefinitely unless I specify an expiration date or condition for its termination. Expiration Date or Condition: _______________.
Signatures
This document must be signed by the Principal in the presence of two witnesses, who must also sign the document, or in the presence of a Notary Public.
Principal’s Signature: ______________________ Date: _______________
Witness 1 Signature: ______________________ Date: _______________
Print Name: ______________________
Witness 2 Signature: ______________________ Date: _______________
Print Name: ______________________
or
Notary Public’s Signature: ______________________ Date: _______________
Print Name: ______________________
My Commission Expires: _______________