Mississippi Power Of Attorney For Health Care Template Page 6
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8PART 3
PRIMARY PHYSICIAN
OPTIONAL
(10) I designate the following physician as my primary physician:
________________________________________________________________________
(name of physician)
_________________________________________________________________________________________________
(address)
(city)
(state)
(zip code)
_____________________
(phone)
OPTIONAL: If the physician I have designated above is not willing, able, or
reasonably available to act as my primary physician, I designate the following physician
as my primary physician:
________________________________________________________________________
(name of physician)
_________________________________________________________________________________________________________
(address)
(city)
(state)
(zip code)
_________________________
(phone)
(11) EFFECT OF COPY:
A copy of this form has the same effect as the original.
(12) SIGNATURES:
Sign and date the form here:
____________________________
___________________________
(date)
(sign your name)
____________________________
___________________________
(address)
(print your name)
____________________________
(city)
(state)
(13) WITNESSES:
This power of attorney will not be valid for making health-care
decisions unless it is either (a) signed by two (2) qualified adult witnesses who are
personally known to you and who are present when you sign or acknowledge your
signature; or (b) acknowledged before a notary public in the state.
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