Power of Attorney for Health Care - Mississippi

5
PART 3
PRIMARY PHYSICIAN
OPTIONAL
(10) I designate the following physician as my primary physician:
________________________________________________________________________
(name of physician)
_________________________________________________________________________________________________
(address) (city) (state) (zip code)
_____________________
(phone)
OPTIONAL: If the physician I have designated above is not willing, able, or
reasonably available to act as my primary physician, I designate the following physician
as my primary physician:
________________________________________________________________________
(name of physician)
_________________________________________________________________________________________________________
(address) (city) (state) (zip code)
_________________________
(phone)
(11) EFFECT OF COPY: A copy of this form has the same effect as the original.
(12) SIGNATURES:
Sign and date the form here:
____________________________ ___________________________
(date) (sign your name)
____________________________ ___________________________
(address) (print your name)
____________________________
(city) (state)
(13) WITNESSES: 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 when you sign or acknowledge your
signature; or (b) acknowledged before a notary public in the state.
Page 5/7
Free Download

Power of Attorney for Health Care - Mississippi PDF

Favor this template? Just fancy it by voting!
  •  
  •  
  •  
  •  
  •  
(0 Votes)
0.0
Related Forms
  •  
  •  
  •  
  •  
  •  
1 Page(s) | 479 Views | 0 Downloads
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1118 Views | 13 Downloads
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1070 Views | 21 Downloads
  •  
  •  
  •  
  •  
  •  
1 Page(s) | 990 Views | 11 Downloads
  •  
  •  
  •  
  •  
  •  
4 Page(s) | 1389 Views | 4 Downloads