Durable Power Of Attorney For Health Care Page 4
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4C.
Third, if my Agent has little or no knowledge of choices I would make, then my Agent and the physicians will
have to make a decision based on what a reasonable person in the same situation would decide. I have confidence
in my Agent’s ability to make decisions in my best interest if my Agent does not have enough information to
follow my preferences.
D.
Finally, if the Durable Power of Attorney for Health Care is determined to be ineffective, or if my Agent is not
able to serve, the Health Care Directive is intended to be used on its own as firm instructions to my health care
providers regarding life-prolonging procedures.
2. Protection of Third Parties Who Rely on My Agent. No person who relies in good faith upon any representations
by my Agent or Alternate Agent shall be liable to me, my estate, my heirs or assigns, for recognizing the Agent’s authority.
3. Revocation of Prior Durable Power of Attorney for Health Care or Health Care Directive. I revoke any prior
living will, declaration or health care directive executed by me. If I have appointed an Agent in a prior durable power of
attorney, I revoke any prior health care durable power of attorney or any health care terms contained in that other durable
power of attorney and intend that this Durable Power for Attorney for Health Care (if completed) and this Health Care
Directive (if completed) replace or supplant earlier documents or provisions of earlier documents.
4. Validity. This document is intended to be valid in any jurisdiction in which it is presented. The provisions of
this document are separable, so that the invalidity of one or more provisions shall not affect any others. A copy of this
document shall be as valid as the original.
IF YOU HAVE COMPLETED THE ENTIRE DOCUMENT OR ONLY THE DIRECTIVE (PART II),
YOU MUST SIGN THIS DOCUMENT IN THE PRESENCE OF TWO WITNESSES.
IN WITNESS WHEREOF, I signed this document on _____________________(month, date),______(year).
___________________________________________
Signature
Printed Name: _______________________________
WITNESSES: The person who signed this document is of sound mind and voluntarily signed this document in our
presence. Each of the undersigned witnesses is at least eighteen years of age.
Signature
____________________________
Signature
____________________________
Print Name
____________________________
Print Name
____________________________
Address
____________________________
Address
____________________________
____________________________
____________________________
NOTARY ACkNOWLEDGMENT
(Only required if Part I or entire document completed.)
STATE OF MISSOURI
)
) SS
COUNTY OF ________________ )
On this ______ day of _________________ (month), ______ (year), before me personally appeared _________________________
_____________, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she
executed the same as his/her free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County or City and state
aforementioned, on the day and year first above written.
____________________________________________________
_________________________________________, Notary Public
(Name Printed)
Part III - The Missouri Bar Form Detachable Insert
Page 4 of 4
Durable Power of Attorney for Health Care and/or Health Care Directive
Revised 9/11
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