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Mississippi Notary Seal _____________________________________________ (Signature of Notary Public) -4- hat he or she executed it. I declare under the penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud or undue influence._______________________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged t___ ) On this ______________, day of _____________________, in the year __________, before me, _____________________________________________________, (insert name of notary public) appeared _______________ Address: ______________________________________ Phone: _______________________________________ -3- Notary (optional instead of Witnesses) State of Mississippi ) ) County of _________________hat I am not a health care provider, nor an employee of a health care provider or facility. _____________________________________________ (Witness Signature) Print Name: ______________________________of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as attorney in fact by this document, and t___________________________ I declare under penalty of perjury under the laws of Mississippi that the principal is personally known to me, that the principal signed or acknowledged this durable power operation of law. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: ____________ principal by blood, marriage or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or byluence, that I am not the person appointed as attorney in fact by this document, and that I am not a health care provider, nor an employee of a health care provider or facility I am not related to the personally known to me, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue infwledge your signature or (b) acknowledged before a notary public in the state Witness Declarations and Signature I declare under penalty of perjury under the laws of Mississippi that the principal istorney 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 acknoate that I understand the purpose and effect of this document. Signed: ____________________________________________________________________ Dated: ______________________________ -2- This power of at_____________________________________________________ _________________________________ Work Telephone Number _________________________________ Home Telephone Number By my signature I do hereby indicble to act as my attorney in fact, I appoint the following person to serve in his or her place: Name:________________________________________________________________________ Home Address: _______________________________________________________________ ______________________________________________________________________________ If the person named as my attorney in fact is not available or is unaereafter amended, being the statutes governing the withdrawal of life-saving mechanisms. Special instructions: _____________________________________________________________ ___________________________are personnel, get information and sign forms necessary to carry out these decisions, and also the power provided in Sections 41-41-101 through 41-41-121, Mississippi Code of 1972, as now enacted or h service, to make a disposition under the state's anatomical gift act, to authorize an autopsy, and to direct the disposition of remains. My attorney in fact also has the authority to talk to health ce or after my death, to the same extent I could make decisions for myself and to the full extent permitted by law, including power to grant, refuse or withdraw consent on my behalf for any health careormed consent with respect to a given health care decision. Subject to my special instructions below, this document gives my attorney in fact the full power to make health care decisions for me, befor____________________ Work Telephone Number _________________________________ Home Telephone Number as my attorney in fact to make health care decisions for me in the event I become unable to give inf____ (name), hereby appoint: Name:________________________________________________________________________ Home Address: _________________________________________________________________ _____________ you sign or acknowledge your signature or (b) acknowledged before a notary public in the state. -1- DURABLE POWER OF ATTORNEY FOR HEALTH CARE I, ____________________________________________________. 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 whenl, therapeutic or scientific purposes, and (c) direct the disposition of your remains. If there is anything in this document that you do not understand, you should ask your lawyer to explain it to younless you otherwise specify in this document, this document gives your agent the power after you die to (a) authorize an autopsy, (b) donate your body or parts thereof for transplant or for educational or other health care provider in writing of the revocation. Your agent has the right to examine your medical records and to consent to this disclosure unless you limit this right in this document. U desires are not known, does anything that is clearly contrary to your best interests. You have the right to revoke the authority of your agent by notifying your agent or your treating doctor, hospitan, a court can take away the power of your agent to make health care decisions for you if your agent (a) authorizes anything that is illegal, (b) acts contrary to your known desires, or (c) where your. This power is subject to any statement of your desires and any limitations that you include in this document. You may state in this document any types of treatment that you do not desire. In additioe document gives your agent authority to consent, to refuse to consent or to withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition to the particular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped or withheld if you object at the time. Thatment necessary to keep you alive. Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respectated in this document or otherwise made known. Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treth care decisions for you. This power exists only as to those health care decisions to which you are unable to give informed consent. The attorney in fact must act consistently with your desires as stmportant legal document. Before executing this document, you should know these important facts: This document gives the person you designate as the attorney in fact (your agent) the power to make healpurchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -4- Power of Attorney for Health Care NOTICE TO PERSON EXECUTING THIS DOCUMENT This is an iu should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. Yoor completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point f the revocation. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect ked under this section, a person is not subject to criminal prosecution or civil liability for acting in good faith reliance upon the durable power of attorney unless the person has actual knowledge otherwise, a valid durable power of attorney for health care revokes any prior durable power of attorney for health care. (5) If authority granted by a durable power of attorney for health care is revothe notification a part of the principal's medical records. -3- (3) It is presumed that the principal has the capacity to revoke a durable power of attorney for health care. (4) Unless it provides oing. (2) If the principal notifies the health care provider in writing that the authority granted to the attorney in fact to make health care decisions is revoked, the health care provider shall make orney for health care by notifying the attorney in fact in writing; (b) Revoke the authority granted to the attorney in fact to make health care decisions by notifying the health care provider in writcipal has the capacity to give a durable power of attorney for health care, the principal may do any of the following: (a) Revoke the appointment of the attorney in fact under the durable power of att durable power of attorney for health care: (a) A treating health care provider; (b) An employee of a treating health care provider. SEC. 41-41-171. Revocation of power. (1) At any time while the prinaw then existing. SEC. 41-41-161. Persons ineligible to be designated as attorney in fact. The following individuals may not be designated as the attorney in fact to make health care decisions under aestate of the principal upon his or her death under any will or codicil thereto of the principal existing at the time of execution of the durable power of attorney for health care or by operation of lttorney for health care shall be someone who is not one of the following: (a) A relative of the principal by blood, marriage or adoption; (b) An individual who would be entitled to any portion of the (a) A health care provider; -2- (b) An employee of a health care provider or facility; or (c) The attorney in fact. (3) At least one (1) of the individuals used as a witness for a durable power of auress, fraud or undue influence. Notary Seal ---------------------------(Signature of Notary Public)" (2) None of the following may be used as witness for a durable power of attorney for health care: s instrument, and acknowledged that he or she executed it. I declare under the penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no d-- ----- (insert name of notary public) appeared ______________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to thiblic at any place within this state, the notary public certifying to the substance of the following: "State of ----- ---"County of ----- ---On this ----- day of -----, in the year -----, before me, --of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law." (ii) Be acknowledged before a notary puprovider or facility." In addition, the declaration of at least one (1) of the witnesses must include the following: "I am not related to the principal by blood, marriage or adoption, and to the best mind and under no duress, fraud or undue influence, that I am not the person appointed as attorney in fact by this document, and that I am not a health care provider, nor an employee of a health care der the laws of ------ that the principal is personally known to me, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound instrument by the principal or the principal's acknowledgement of the signature or of the instrument, each witness making the following declaration in substance: "I declare under penalty of perjury unwer of attorney contains the date of its execution and is witnessed by one (1) of the following methods: (i) Be signed by at least two (2) individuals each of whom witnessed either the signing of the h care decisions only if the following requirements are satisfied: -1- (a) The durable power of attorney specifically authorizes the attorney in fact to make health care decisions; (b) The durable potorney in fact makes health care decisions. SEC. 41-41-159. Requirements for attorney in fact to make health care decisions; persons who may witness for power. (1) An attorney in fact shall make healtsociation, the state, a city, county, city and county or other public entity or governmental subdivision or agency or any other legal entity; (g) "Principal" shall mean the individual for which the atd or permitted by the law of this state to administer health care in the ordinary course of business or practice of a profession; (f) "Person" shall include an individual, corporation, partnership, as "Health care decision" shall mean consent, refusal of consent or withdrawal of consent to health care; (e) "Health care provider" shall mean a person who is licensed, certified or otherwise authorizeealth care decisions on behalf of the principal; (c) "Health care" shall mean any care, treatment, service or procedure to maintain, diagnose or treat an individual's physical or mental condition; (d)able to give informed consent with respect to a given health care decision; (b) "Attorney in fact" shall mean one who is designated as an agent in a durable power of attorney for health care to make h-151 through 41-41-183: (a) "Durable power of attorney for health care" shall mean a document that authorizes an attorney in fact to make health care decisions for the principal if the principal is untatutes. The following are useful excerpts from the Mississippi Statutes relating to the Mississippi Power of Attorney for Health Care Form. SEC. 41-41-155. Definitions. For purposes of Sections 41-41 Mississippi Durable Power of Attorney for Health Care Form. This Mississippi Durable Power of Attorney for Health Care is based on Title 41 Chapter 041 Section 41-41-163 et. Seq. of the Mississippi SInformation and Instructions Mississippi Durable Power of Attorney for Health Care This package contains (1) Information and Instruction for Mississippi Durable Power of Attorney for Health Care ; (2) Mississippi