Durable Power of Attorney for Health Care and Health Care Directive

DURABLE POWER OF ATTORNEY FOR HEALTH CARE
AND/OR HEALTH CARE DIRECTIVE OF
(Print full name here) _________________________________________________________________
(Address, City, State, Zip)_______________________________________________________________
PART I. DURABLE POWER OF ATTORNEY FOR HEALTH CARE
(
If you DO NOT WISH to name someone to serve as your decision-making Agent,
mark an “X” through Part I on pages 1 & 2 and continue on to Part II.)
1. Selection of Agent. I, ______________________________________________, currently a resident of
__________________
County, Missouri, appoint the following person as my true and lawful attorney-in-fact (“Agent”):
Name: ____________________________________________________
Address: ____________________________________________________
____________________________________________________
Phone(s): 1
st
_______________________ 2
nd
______________________
2. Alternate Agent. If my Agent resigns or is not able or available to make health care decisions for me, or if an Agent
named by me is divorced from me or is my spouse and legally separated from me, I appoint the following persons in the
order named below to serve as my alternate Agent and to have the same powers as my Agent:
First Alternate Agent:
Name: _____________________________________
Address: _____________________________________
_____________________________________
Phone(s): 1
st
__________________________________
2
nd
__________________________________
3. Durability. This is a Durable Power of Attorney, and the authority of my Agent, when effective, shall not terminate
or be void or voidable if I am or become disabled or incapacitated or in the event of later uncertainty as to whether I am
dead or alive.
4. Effective Date as to Health Care Decision Making. This Durable Power of Attorney is effective as to health care
decision making when I am incapacitated and unable to make and communicate a health care decision as certied by
(check one of the following boxes): one physician OR two physicians.
5. Agent’s Powers. I grant to my Agent full authority as to health care decision making to:
A. Give consent to, prohibit, or withdraw any type of health care, long-term care, hospice or palliative care, medical
care, treatment, or procedure, either in my residence or a facility outside of my residence, even if my death may
result, including, but not limited to, an out of hospital do-not-resuscitate order, with the following specic
authorization (initial one of the following boxes to indicate your choice):
I wish to AUTHORIZE my Agent to direct a health care provider to withhold or withdraw articially
supplied nutrition and hydration (including tube feeding of food and water);
OR I DO NOT AUTHORIZE my Agent to direct a health care provider to withhold or withdraw
articially supplied nutrition and hydration (including tube feeding of food and water);
B. Make all necessary arrangements for health care services on my behalf and to hire and re medical personnel
responsible for my care;
Initials _________ Part I - After completed, detach, make copies and give to your health care providers. Page 1 of 4
Durable Power of Attorney for Health Care and/or Health Care Directive Revised 2/14
Second Alternate Agent:
Name: _____________________________________
Address: _____________________________________
_____________________________________
Phone(s): 1
st
__________________________________
2
nd
__________________________________
Initials
Initials
Page 1/4
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