Attorney-Approved Medical Power of Attorney Template for Mississippi

Mississippi Medical Power of Attorney

This Medical Power of Attorney is established under the Mississippi Uniform Health-Care Decisions Act and allows you to nominate a trusted person to make medical decisions on your behalf should you become unable to do so. This document is legally binding in the state of Mississippi.

Principal's Information:

• Full Name: ___________________________
• Address: _____________________________
• City: _____________________________
• State: Mississippi
• Zip Code: ___________________________
• Phone Number: ________________________

Agent's Information:

• Full Name: ___________________________
• Address: _____________________________
• City: _____________________________
• State: ____________________________
• Zip Code: ___________________________
• Phone Number: ________________________

Alternate Agent's Information (Optional):

• Full Name: ___________________________
• Address: _____________________________
• City: _____________________________
• State: ____________________________
• Zip Code: ___________________________
• Phone Number: ________________________

Authority Granted to Agent:

This document grants my health care agent the authority to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nourishment and hydration, and all other forms of health care to keep me alive, except as I state otherwise in this document. The powers of the health care agent are subject to any specific limitations I set forth below.

Special Instructions:

Effective Date and Duration:

This Medical Power of Attorney becomes effective immediately upon my inability to make my own health care decisions and will remain in effect indefinitely unless I specify a termination date or condition below.

Termination Date/Condition: _________________________

Signature of Principal: _______________________ Date: ___________

State of Mississippi, County of _______________

On this day, before me appeared _________________________ (Principal's Name), to me known to be the person described in and who executed the foregoing instrument, and acknowledged that (s)he executed the same as his/her free act and deed.

Notary Public: _______________________

My commission expires: ______________

Acknowledgment by Agent:

I, _________________________ (Agent's Name), hereby acknowledge that I have been appointed as health care agent under the above Medical Power of Attorney and accept this appointment. I understand my responsibilities as an agent and commit to acting in the best interests of the principal, consistent with their desires as stated in this document or made known to me in some other way.

Signature of Agent: _______________________ Date: ___________

Acknowledgment by Alternate Agent (If applicable):

I, _________________________ (Alternate Agent's Name), hereby acknowledge that I have been appointed as an alternate health care agent under the above Medical Power of Attorney and accept this appointment. Should the primary agent become unwilling or unable to serve, I commit to acting in the best interests of the principal, consistent with their desires as stated in this document or made known to me in some other way.

Signature of Alternate Agent: _______________________ Date: ___________