Mississippi Power Of Attorney For Health Care Template Page 3
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8PART 1
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.
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)
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