Missouri Medical Power of Attorney Form

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Updated February 20, 2023

A Missouri medical power of attorney is a form that allows a principal to assign a representative to make health care decisions if they cannot make health care decisions on their own. It may also provide peace of mind knowing that a loved one, who has your best interests in mind, is empowered to make decisions when you are in a situation where you can’t communicate your wishes. In most cases, the principal will need a notary and two witnesses to witness their signature on this document.


How to Write

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1 – Open The Directive Form On This Page

Download the form and review each point. The form is easily attainable as a PDF, Word, or ODT file through the buttons on this page. You may fill in Part I which appoints someone to represent your interests, or you may fill in Part II which sets forth your medical treatment preferences, or you may fill out both.

2 – Indicate Who Is Issuing This Paperwork By Completing The Title

Use the first blank line on this page to complete the document’s Title with the Full Name of the Principal. Make sure to print the Principal’s Name clearly after the words “Print Full Name Here”

The Principal’s report should continue with his or her Complete Address. Use the space labeled “Address, City, State, Zip” to present the Physical Address of the Principal’s Residence.

3 – The Principal Designation Of The Health Care Agent

The first part “Durable Power Of Attorney For Health Care” will provide the necessary Principal Declaration in Item 1. We will begin by supplying the Principal’s Full Name of the Principal just before the words “currently a resident of.”

On the next available blank line, fill in the County where the Principal lives.

Now, locate the blank lines with the bold labels “Name,” “Address, and “Phone(s)” These will refer to the individual being named as the Attorney-in-Fact. Enter the Full Legal Name of the Attorney-in-Fact on the line labeled “Name” and the Complete Residential Address of the Attorney-in-Fact on the blank line labeled “Address.” Finally, on the blank line labeled “Phone(s),” two separate spaces “1st” and “2nd” have been provided so that you may enter the Attorney-in-Fact’s Contact Phone Numbers. If the Attorney-in-Fact has only one Phone Number, record this in the first space. Make sure any Phone Numbers reported here are well maintained by the Attorney-in-Fact.

Item 2, labeled “Alternate Agent,” will address the idea of back-up Agents. If desired, the Principal may choose up to two individuals to assume the responsibilities and representational Powers of the Health Care Agent should this individual be unable or ineligible to fulfill the Health Care Agent role. Enter the Name, Address, and Phone Numbers of the individual who will assume Health Care Agent Powers should the primary Agent not do so using the blank lines in the column labeled “First Alternate Agent.”

Enter the Name, Address, and Phone Number(s) of the individual who will assume Health Care Agent Powers should the Primary Health Care Agent and First Alternate Agent be unable or ineligible to act as the Health Care Agent in the column labeled “Second Alternate Agent.”

In Item 4, we must address the “Effective Date As To Health Care Decision Making.” By default, the Health Care Powers listed in this document will become Effective when the Principal has been given a written diagnosis of being unable to communicate or is incapacitated. If the Powers in this document may become Effective with a written diagnosis from One Physician, then mark the first checkbox. If Two Physician Diagnosis will be required to set the Powers in this document as active, then mark the second checkbox in this paragraph. Item Five will discuss the “Agent’s Powers,” and will require some information to define it. First, we will turn our attention to if the Principal wishes to give the Authority to accept or deny artificial Nutrition and Hydration administered to the Principal. If the Principal intends to empower the Health Care Agent with the right to deny the Principal Artificial Nutrition and Hydration on his or her behalf, the Principal will need to initial the first box.

If the Principal does not wish to empower the Health Care Agent with the right to decide if the Principal should receive artificial Nutrition and Hydration, the Principal should initial the second statement. The Principal will need to initial the blank line at the bottom left of this page. The next lettered items will appoint the Health Care Agent with the common tasks such an entity is expected to fulfill. Item B grants the Agent the Power to hire and fire Medical Professionals caring for the Principal. Item C empowers the Agent with the Principal Authority to determine where the Principal receives (or does not receive) medical care. Item D grants the Agent the Power to enforce this document and provides a waiver for those who obey it. Item E names the Agent as the Principal’s HIPAA Representative. The Principal may cross out or remove any of these statements to restrict the Agent from carrying out the actions they describe, but it is suggested he or she consult an appropriate professional before doing so. Now, in the section labeled “Effective Date As To Other Authority,” the Principal which decisions the Health Care Agent may make outside of direct Health Care. If the Principal wishes the Attorney-in-Fact to determine what happens to his or her body after death, the Principal will need to initial the first box in Item Six. If the Principal gives his or her content to a postmortem examination of his or her body, the Principal will need to initial the second box in this item. The Principal can give the Health Care Agent the Principal Power to delegate Health Care Decision Making Powers to another party (Delegee), the Principal will need to initial the third box. The fourth box should be initialed if the Principal grants approval to make Anatomical Gifts of his or her remains. If this box is initialed the area directly below it must be attended to. If the Principal has given his or her Approval to make Anatomical Gifts of his or her remains, you may indicate what Purpose Anatomical Gifts may be made for. Locate the box with the statement “My Donations Are For The Following Purposes,” then mark any of the check boxes to indicate what Purpose the Principal’s Anatomical Gift may be made for. The Principal may indicate the Purpose(s) to be Transplantation, Therapy, Research, Education, or all the above. In the adjacent box, Next, you may indicate if the Principal will donate any Body Parts allowed by law by marking the first checkbox after the words “Gift Specifications.” If there are any restrictions, then mark the second checkbox and document the restrictions on the blank space provided. If the Principal does not wish to make Anatomical Gifts of his or her remains then he or she must initial the box to the left of the label “Prohibition Of Anatomical Gifts.”

The Principal must initial the blank space at the bottom left-hand corner of this page. Part II has been provided so that specific Directives of the Principal may be addressed directly. In Item 2 of this part, the Principal should initial the boxes corresponding to the statements that define his or her instructions when he or she has been diagnosed with a terminal illness/condition, incapacitated, or is rendered permanently unconscious with no real expectation of recovery. Each of the Medical Interventions below must be withheld if they bear the Principal initials the corresponding box. The Principal may choose to withhold “Artificially Supplied Nutrition And Hydration,” “Surgery Or Other Invasive Procedures,” “Heart-Lung Resuscitation (CPR),” “Antibiotics,” “Dialysis,” “Mechanical Ventilator (Respirator),” “Chemotherapy,” “Radiation Therapy,” and/or any “Other Procedures…” If the Principal needs to specify a Procedure or Intervention not on this list to withhold, this may be done by documenting them on the blank line after the words “Other Procedures Specified By Me (Insert).” The Principal also has the opportunity to simply forbid “All Other Life-Prolonging” Medical Or Surgical Procedures” by initialing the last box.Part III will begin with the “Relationship Between Durable Power Of Attorney For Health Care And Health Care Directive. Several statements labeled “A” through “D” will have some basic preferences the Principal encourages the Agent to take into consideration. The next three items discuss “Protection Of Third Parties Who Rely” on the Agent, “Revocation” of Prior Powers, and the “Validity” of this directive. The Principal may choose to remove any of these items and their components but it is strongly recommended the Principal consults with a Physician or Attorney before doing so. The Principal must initial the bottom of the third page.

3 – The Principal Signature Must Be Presented To Execute This Form

Use the two blank lines directly under the bold words “You Must Sign This Document In The Presence Of Two Witnesses,” to report the Date of Signature. The Month and Day this document is being signed must be entered on the first space and the second blank space will require the Year of signing recorded.

Next, the Principal must sign his or her Name on the “Signature” line then print his or her Name on the “Printed Name” line. The “Witnesses” statement, will provide two distinct columns so that each Witness will be able to Sign and Print his or her Name then, record his or her Address. The last section is the “Notary Acknowledgement” section will need to be filled out by the Notary Public observing the Principal signing. Only this entity may supply the items required then notarize this form with his or her credentials.