Healthcare Power of Attorney - Mississippi

MISSISSIPPI HEALTH-CARE POWER OF ATTORNEY

Agent-Focused Advance Health-Care Directive

1. Principal

I, [FULL LEGAL NAME], born [__/__/____], residing at [________________________________], make this health-care power of attorney voluntarily.

Telephone / email: [________________________________]

2. Primary Health-Care Agent

I designate the following individual as my health-care agent:

3. Alternate Health-Care Agents

If my primary agent is unable or unwilling to act, I designate the following alternates in order:

4. When Agent Authority Begins — Choose One

☐ Default incapacity activation. My agent's authority begins when my primary physician determines that I lack capacity to make my own health-care decisions.

☐ Immediate authority. My agent may make health-care decisions for me immediately, subject to my right to make and communicate my own decisions while I have capacity.

☐ Other activation event or condition: [________________________________________]

My current decisions control while I have capacity. If I later regain capacity for a decision, I resume authority over that decision.

5. General Authority

Subject to my instructions and limits, my agent may make any health-care decision I could make, including decisions to consent to, refuse, or withdraw consent to health care; select or discharge providers and institutions; and arrange admission, transfer, or discharge related to my care.

Under Mississippi's Health-Care Decisions Act, a “health-care decision” does not include an anatomical gift. This document does not itself authorize organ or tissue donation; I will use separate, legally appropriate documentation for that purpose.

6. Medical Information and Records

Unless I limit authority below, my acting agent has the same rights I would have to request, receive, examine, copy, and consent to disclosure of medical or other health-care information needed to make decisions for me.

Limits on information or records authority:

[____________________________________________________________]

7. Decision Standard and Agent Duties

My agent must make decisions in accordance with this power of attorney and other instructions I have given, if known. If my wishes are not known, my agent must act in my best interest. In deciding my best interest, my agent must consider my personal values to the extent known.

My values, goals, beliefs, and known wishes are:

[____________________________________________________________]

8. Treatment Instructions and Limits

My agent's authority is subject to these instructions:

Other limits on my agent's authority:

[____________________________________________________________]

These instructions are not a stand-alone emergency medical order. I will discuss any separate order needed for emergency response with my clinician.

9. Primary Physician — Optional Nomination

I nominate the following physician as my primary physician:

Name / practice: [________________________________]

Address: [________________________________]

Telephone / email: [________________________________]

If that physician is unavailable or unwilling to act, I nominate:

[____________________________________________________________]

10. Spouse-Agent and Relationship Proceedings

Unless this document expressly provides otherwise, a decree of annulment, divorce, dissolution of marriage, or legal separation revokes a designation of my spouse as agent.

☐ Apply that statutory default.

☐ I intend the spouse-agent designation above to continue notwithstanding such a decree, to the extent permitted by law.

11. Revocation and Copies

I may revoke an agent designation only by signing a writing or by personally informing my supervising health-care provider. I may revoke another part of this directive at any time and in any manner that communicates an intent to revoke. I will promptly tell my agent and providers of any revocation or replacement.

A copy of this power of attorney has the same effect as the original.

12. Principal's Signature

I understand this power of attorney and sign it voluntarily on the date shown.

Principal signature: [________________________________] Date: [__/__/____]

Printed name: [________________________________]

Address: [____________________________________________________________]

13. Execution Verification — Choose One

Complete either Option A or Option B. Do not use an agent or alternate named in this document as a witness. A health-care provider, an employee of a health-care provider, or an operator or employee of a health-care institution where I receive care may not serve as a witness. If witnesses are used, at least one must be neither related to me by blood, marriage, or adoption nor entitled to any part of my estate under a will or by operation of law when I die.

Option A — Two Adult Witnesses

Each witness declares that the principal signed or acknowledged this power of attorney in the witness's presence and appeared to act voluntarily.

Option B — Mississippi Notary Acknowledgment

State of Mississippi

County of [________________]

On [__/__/____], before me, the undersigned notarial officer, personally appeared [PRINCIPAL NAME], proved through satisfactory evidence to be the person whose name is signed above, and acknowledged executing this health-care power of attorney voluntarily.

Notarial officer signature: [________________________________]

Printed name and title: [________________________________]

Commission expires: [__/__/____] Seal: [________________]

14. Optional Agent Acknowledgment

Agent acceptance is not a substitute for the principal's execution and required witness or notary verification. By signing below, each named person acknowledges receiving this document and agrees to follow the principal's instructions and Mississippi law when acting.

Primary agent: [________________________________] Date: [__/__/____]

First alternate: [________________________________] Date: [__/__/____]

Second alternate: [________________________________] Date: [__/__/____]

15. Distribution Checklist

☐ Principal retained a copy.

☐ Primary and alternate agents received copies.

☐ Primary physician and other treating providers received copies.

☐ Hospital, hospice, home-health agency, or care facility received a copy.

☐ Family or support person received a copy: [________________________________]

☐ Mississippi attorney reviewed the completed directive.

Sources and References

• Miss. Code Ann. § 41-41-203 — Definitions
• Miss. Code Ann. § 41-41-205 — Health-Care Powers of Attorney
• Miss. Code Ann. § 41-41-207 — Revocation and Spouse-Agent Effect
• Miss. Code Ann. § 41-41-209 — Statutory Form
• Miss. Code Ann. § 41-41-215 — Provider Compliance and Transfer
• Miss. Code Ann. § 41-41-217 — Health-Care Information
• Miss. Code Ann. § 41-41-223 — Current Decisions and Capacity Presumption
• Miss. Code Ann. § 41-41-225 — Copies