Missouri Medical Power of Attorney
This Medical Power of Attorney is established in accordance with the Missouri Durable Power of Attorney for Health Care Act and is intended to authorize another person to make health care decisions on the principal's behalf should they become unable to make such decisions themselves.
Principal Information
Full Name: ___________________________________________
Date of Birth: ________________________________________
Address: _____________________________________________
City: ______________________ State: MO Zip: ___________
Attorney-in-Fact (Agent) Information
Full Name: ___________________________________________
Relationship to Principal: _____________________________
Primary Phone: _______________________________________
Alternative Phone: ___________________________________
Email Address: ______________________________________
Address: _____________________________________________
City: ______________________ State: MO Zip: ___________
This document grants the designated Attorney-in-Fact (or Agent) the power to make health care decisions on behalf of the Principal under the following conditions:
- When a physician determines that the Principal is unable to understand the nature and consequences of health care decisions;
- When the Principal is unable to communicate their health care decision-making needs due to any reason;
- Any decisions made by the Attorney-in-Fact shall adhere strictly to the wishes expressed by the Principal in this document or otherwise communicated.
Special Instructions:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature and Acknowledgment
By signing below, the Principal affirms their understanding of the nature and purpose of this document and grants the above-named Attorney-in-Fact the power to make health care decisions on their behalf.
Principal's Signature: _______________________________ Date: _________
Attorney-in-Fact's Signature: ________________________ Date: _________
This document was signed in the presence of two witnesses, who are not the appointed Attorney-in-Fact, nor related to the Principal by blood, marriage, or adoption, and who do not have a claim against any portion of the Principal’s estate upon their death.
Witness 1 Signature: ________________________________ Date: _________
Witness 2 Signature: ________________________________ Date: _________
State of Missouri
County of ___________________
This document was acknowledged before me on (date) ______________ by (name of Principal) ________________________________________________.
Notary Public: _______________________________________
(Seal)