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Mississippi Medical Power of Attorney Form

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Mississippi Medical Power of Attorney Form Page 2
Mississippi Medical Power of Attorney Form
2
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.
Mississippi Medical Power of Attorney Form