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DURABLE POWER OF ATTORNEY FOR HEALTH CARE

AND/OR HEALTH CARE DIRECTIVE OF

_________________________________________________________________

(Print full name here)

_______________________________________________________________

(Address, City, State, Zip)

PART I. DURABLE POWER OF ATTORNEY FOR HEALTH CARE

(If you DO NOT WISH to name someone to serve as your decision-making Agent,

mark an “X” through Part I on pages 1 & 2 and continue on to Part II.)

1. Selection of Agent. I, ______________________________________________, currently a resident of

__________________ County, Missouri, appoint the following person as my true and lawful attorney-in-fact (“Agent”):

Select County

Name:

____________________________________________________

Address:

____________________________________________________

Phone(s):

_______________________

______________________

2. Alternate Agent. If my Agent resigns or is not able or available to make health care decisions for me, or if an Agent

named by me is divorced from me or is my spouse and legally separated from me, I appoint the following persons in the

order named below to serve as my alternate Agent and to have the same powers as my Agent:

First Alternate Agent:

Second Alternate Agent:

Name:

_____________________________________

Name:

_____________________________________

Address: _____________________________________

_____________________________________

Phone(s): 1

__________________________________

Phone(s): 1

__________________________________

3. Durability. This is a Durable Power of Attorney, and the authority of my Agent, when effective, shall not terminate

or be void or voidable if I am or become disabled or incapacitated or in the event of later uncertainty as to whether I am

dead or alive.

4. Effective Date as to Health Care Decision Making. This Durable Power of Attorney is effective as to health care

decision making when I am incapacitated and unable to make and communicate a health care decision as certified by

□

(check one of the following boxes):

one physician

two physicians.

5. Agent’s Powers. I grant to my Agent full authority as to health care decision making to:

A. Give consent to, prohibit, or withdraw any type of health care, long-term care, hospice or palliative care, medical

care, treatment, or procedure, either in my residence or a facility outside of my residence, even if my death may

result, including, but not limited to, an out of hospital do-not-resuscitate order, with the following specific

authorization (initial one of the following boxes to indicate your choice):

I wish to AUTHORIZE my Agent to direct a health care provider to withhold or withdraw artificially

Initials

supplied nutrition and hydration (including tube feeding of food and water);

OR I DO NOT AUTHORIZE my Agent to direct a health care provider to withhold or withdraw

artificially supplied nutrition and hydration (including tube feeding of food and water);

Initials

B. Make all necessary arrangements for health care services on my behalf and to hire and fire medical personnel

responsible for my care;

Initials _________

Part I - After completed, detach, make copies and give to your health care providers.

Page 1 of 4

Durable Power of Attorney for Health Care and/or Health Care Directive

Revised 2/14

Durable Power Of Attorney For Health Care

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