Missouri Medical Power of Attorney
This document is created in accordance with the laws of the State of Missouri.
I, [Your Full Name], residing at [Your Address], understand that this Medical Power of Attorney enables me to appoint someone to make healthcare decisions on my behalf in the event that I am unable to do so.
1. APPOINTMENT OF AGENT:
I hereby appoint the following person as my agent to make healthcare decisions for me:
Agent's Name: [Agent's Full Name]
Agent's Address: [Agent's Address]
Agent's Phone Number: [Agent's Phone Number]
2. ALTERNATE AGENT:
If the above-named agent is unable or unwilling to act, I appoint the following person as my alternate agent:
Alternate Agent's Name: [Alternate Agent's Full Name]
Alternate Agent's Address: [Alternate Agent's Address]
Alternate Agent's Phone Number: [Alternate Agent's Phone Number]
3. EFFECTIVE DATE:
This Medical Power of Attorney becomes effective when my physician determines that I am unable to make my own healthcare decisions.
4. LIMITATIONS:
If there are specific limitations to the authority granted to my agent, please specify:
Limitations: [Describe any limitations or write 'None']
5. SIGNATURE:
This document must be signed by me as the principal and must be dated. My signature below indicates that I voluntarily choose to create this Medical Power of Attorney.
Signature of Principal: _________________________
Date: _________________________
6. WITNESSES:
Two witnesses must sign below. They must be at least 18 years old and should not be designated as my agent or alternate agent.
Witness 1 Name: _________________________ Date: _________________________
Witness 2 Name: _________________________ Date: _________________________
This Medical Power of Attorney is created in accordance with the Revised Statutes of Missouri, Chapter 404, and is intended to be as comprehensive as possible for my healthcare decisions.