Mississippi Advance Directive Form

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A Mississippi advance care directive is a document that allows a person to make future healthcare plans by electing an agent to speak on their behalf and set life-ending treatment options. An advance directive is common for older people and those with high-risk health conditions. It’s a plan to prepare a patient in the chance they are unconscious and unable to speak for themselves.

Three (3) Parts

  • Durable Power of Attorney for Healthcare;
  • Living Will; and
  • Signature Area.

Table of Contents


Statute – Title 41, Chapter 41 (Mississippi Health Care Decisions Act)

Signing Requirements (§ 41-41-209) – Two (2) witnesses or a notary public.

State Definition – (§ 41-41-203(b)) – “Advance health-care directive” means an individual instruction or a power of attorney for health care.

Versions (5)


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Forest Health

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Mississippi Hospice and Palliative Care

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North Mississippi Health Services

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How to Write

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1 – Open The Paperwork Required To Name A Health Care Agent Or Document A Patient’s Directive

The form on this page will provide the ability to either appoint an individual with Health Care Agent Powers of Decision, Provide Health Care Instructions, or both. Open this form using one of the buttons on this page (labeled “PDF,” “ODT,” and “Word”). Once this document has been obtained, the Principal Patient should read through its entirety

2 – Designate The Health Care Agent(s)

In Part I, Item 1, enter the Legal Name of the individual determined to be the Principal Patient’s Health Care Agent on the blank line labeled “Name of Individual You Choose As Agent.” The line directly below this should have the Full Residential Address of the Health Care Agent recorded on it. Enter the Health Care Agent’s Street Address directly above the word “Address,” City directly above the word “City,” State directly above the word “State,” and Zip Code directly above the label “Zip Code.”The third blank line in this item will need the Home and Work Telephone Numbers of the Health Care Agent entered on it. There will be a separate area for “Home Phone” and “Work Phone.”The next two areas in this item are optional. The Principal Patient may have named one or two Alternate Health Care Agents to step in should the Primary Health Care Agent’s be revoked or if he or she cannot act as such. If the Principal has decided upon an individual who may assume the Principal Power to make Health Care Decisions (on behalf of the Principal), then locate the statement beginning with “OPTIONAL: If I Revoke My Agent’s Authority…” and enter the Full Name of the Alternate Health Care Agent on the blank line labeled “Name of Individual You Choose As First Alternate Agent.” Similarly, to the previous area, record the Full Residential Address, Home Telephone Number, and Work Telephone Number of the Alternate Health Care Agent on the two blank lines below the Name.If the Principal Patient has decided upon a second individual who may act as the Health Care Agent, should both previously named individuals have their Power revoked or are generally unable to act as such, then enter the next Alternate Health Care Agent’s Name, Address, Home Phone Number, and Work Phone Number using the three blank lines below the paragraph beginning with the words “Optional: If I Revoke The Authority Of My Agent And First Alternate Agent.”

3 – Detail What The Health Care Agent May Do On Behalf Of The Principal Patient

Item 2 will provide the declaration statement required by the Principal to provide the Health Care Agent(s) named in this form with the Power to make “…all Health-Care Decisions” on his or her behalf. If, however, the Principal has certain exceptions, concerns, or preferences, they should be detailed on the blank lines below the words “(2) Agent’s Authority.” If necessary, you may add more lines or continue on an attachment to provide a Full Report.Item 3 will seek to define when the Health Care Agent’s Principal Decision Making Power goes into Effect. By default, they will go into Effect when/if the Principal Patient is declared unable to communicate effectively or to make Health Care Decisions by his or her Primary Physician. If the Principal Patient prefers the Powers in this document to become effective immediately, he or she must mark the bracket box in Item 3 between the words “If I Mark This Box” and “My Agent’s Authority…”The next two items will further define some Principal Preferences. Item 4 will grant the Health Care Agent to make Decisions based on Principal Preferences if the current situation was not covered.

Item 5 will nominate the Health Care Agent(s) named above as Guardian(s) to his or her estate and person if the courts deem one is necessary. Any part of these statements, or their entirety, may be deleted or crossed out to exclude them from being included in the Principal Decision-Making Powers delivered to the Health Care Agent.

4 – Provide The Health Care Instructions The Patient Expects Carried Out

Part 2 will document the Principal Preferences the Health Care Agent (and all involved with the Principal Patient’s Health Care) should be aware of as the Principal’s Instructions. Item 6 will begin this report by requesting one of two checkboxes to be marked to indicate the Principal’s feeling regarding “End-of-Life Decisions.” If the Principal prefers not to have his or her life prolonged when faced with an incurable/irreversible condition that is terminal, being permanently unconscious, or a condition whose risks/burden of medical Treatment will “Outweigh Expected Benefits,” then he or she should mark the checkbox labeled “(a) Choice Not To Prolong Life.” However, if the Principal wishes to have his or her life Prolonged when faced with such a condition then, he or she should mark the checkbox “(b) Choice TO Prolong Life.”In Item 7, the Principal may choose to receive Artificial Nutrition and Hydration (regardless of the choice he or she made in Item 6) when necessary by marking the box between the words “If I Mark This Box” and “Artificial Nutrition…”Item 8 shall direct that “Relief From Pain” should be provided even if it may cause the Principal Patient to die prematurely. The Principal may have exceptions to this. If so, these should be recorded on the blank lines provided in this item. The Principal may wish to provide additional instructions or details to the Health Care Directive being documented there. If so, use the blank lines in Item 9 to document such additional items. Anything recorded here should be a complete account of Principal Preferences, so if there is not enough room, you may continue on an attachment or add more lines to this document.

5 – The Option To Name A Primary Physician May Be

In Part 3, the option to name the Principal Patient’s Primary Physician has been made available. If this is desired, then enter the Full Name of the Primary Physician on the first blank line in Item 10. Then on the second blank line in Item 10, enter the Primary Physician’s Address. Finally, enter the Primary Physician’s Telephone Number on the third blank line in this item. In addition to the Principal’s Primary Physician, an Alternate Physician may be named in case the one named above is unable, unwilling, or unavailable to act as the Principal’s Primary Physician. To document an Alternate Physician, locate the paragraph beginning with the words “Optional: If The Physician I Have Designated Above…” then, enter the Alternate Physician’s Full Name on the first blank line. Then, on the second blank line, enter the Alternate Physician’s Full Address. Lastly, enter the Alternate Physician’s telephone Number on the third blank line

6 – The Principal’s Signature Shall Authenticate The Principal’s Preferences Here

The Principal will need to sign this form to finalize it properly. Two columns below the words “(12) Signatures: Sign And Date The Form Here” have been provided. In the column on the left, the Principal must enter the Date he or she signs this form and his or her Full Address. Then in the column on the right, the Principal must sign and print his or her Name on the two blank spaces provided. This form must be signed by the Principal in order for it to be Effective.

This signature must be adequately substantiated by another party. This may be either two Witnesses or a Notary Public. The Principal may decide to choose the method he or she prefers. If the signing occurs before two Witnesses then each Witness must read the text in “Alternative No. 1,” then provide the Date of Signature, his or her Address, his or her Signature, and his or her Printed Name. There will be two paragraphs so that each Witness will have their own areas.

If the Principal will substantiate his or her Signature through a Notary Public, the Notary Public will supply the items in “Alternative No. 2.”

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