Durable Power Of Attorney For Health Care
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11Part I. Durable Power of Attorney for Health Care
• If you do NOT wish to name an agent to make health care decisions for you,
write your initials in the box to the right and got to Part II.
Initials
This form has been prepared to comply with the “Durable Power of Attorney for Health Care
Act” of Missouri.
1.
Selection of Agent. I appoint:
It is suggested that only one
Name: ______________________________________
Agent be named. However,
Address: ____________________________________
if more than one Agent is
____________________________________________
named, any one may act
Telephone: ___________________________________
individually unless you
specify otherwise.
as my Agent.
2. Alternate Agents. Only an Agent named by me may act under this Durable Power of Attorney.
If my Agent resigns or is not able or available to make health care decisions for me, of if an Agent
named by me is divorced from me or is my spouse and legally separated from me, I appoint the
person(s) named below (in the order named if more than one):
First Alternate Agent
Second Alternate Agent
Name: ___________________________________
Name: _______________________________
Address: _________________________________
Address: _____________________________
_________________________________________
____________________________________
Telephone: ________________________________
Telephone: ___________________________
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.
7.
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