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DURABLE POWER OF ATTORNEY FOR HEALTH CARE
. DESIGNATION OF AGENT. I, , of , , appoint:
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
as my Agent to make health care decisions for me if I am incapacitated and am unable to make my health care decisions.
NOTICE: Your attending physician or an employee of your attending physician, or an owner, operator or employee of a health care facility in which you are a resident, shall not serve as your Attorney-in-Fact unless: (1) You are related by affinity or consanguinity within the second degree; or (2) You are members of the same community of persons who are bound by vows to a religious life and who conduct or assist in the conducting of religious services and actually and regularly engage in religious, benevolent, charitable, or educational ministry, or the performance of health care services.
. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney for Health Care. This Power of Attorney shall take effect upon my incompetency and shall not terminate if I become disabled.
. AGENT'S POWERS. Subject to any limitations in this document, I grant to my Agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. My Agent's authority shall include, but is not limited to, the authority to:
1. Give consent to, prohibit or withdraw any type of health care, medical care, treatment or procedure, even if my death may result,
THE AUTHORITY TO DIRECT A HEALTH CARE PROVIDER TO WITHHOLD OR WITHDRAW ARTIFICIALLY SUPPLIED NUTRITION AND HYDRATION (INCLUDING TUBE FEEDING OF FOOD AND WATER).
(WRITE YOUR INITIALS ON THE LINE TO THE RIGHT.)
___________________
INITIALS
2. Making all necessary arrangements for health care services on my behalf, and to hire and fire medical personnel responsible for my care;
3. Moving me into or out of any health care facility (even if against medical advice to obtain compliance with the decisions of my Agent; and
4. Taking any other action necessary to do what I authorize here, including (but not limited to) granting any waiver or release from liability required by any health care provider, and taking any legal action at the expense of my estate to enforce this Durable Power of Attorney.
In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent. My Agent shall seek and consider information concerning my medical diagnosis, the prognosis and the benefits and burdens of treatment.
. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS. I to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains.
. AGENT'S FINANCIAL LIABILITY AND COMPENSATION. My Agent acting under this Durable Power of Attorney will incur no personal financial liability. My Agent shall not be entitled to compensation for services performed under this Durable Power of Attorney, but my Agent shall be entitled to reimbursement for all reasonable expenses incurred as a result of carrying out any provision hereof.
. EFFECTIVE DATE AND DURABILITY. The Durable Power of Attorney is effective when TWO physicians decide that I am incapacitated and unable to make and communicate a health care decision.
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate my Agent (or Alternate Agent) to serve as my Guardian.
. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate
| Name: |
| Address: |
| , |
to serve as my Guardian.
. GENERAL PROVISIONS.
1. REVOCATION. This document may be revoked at any time and in any manner by which I am able to communicate the intent to revoke. Revocation shall be effective upon communication of such revocation to my Agent or to my attending physician or health care provider.
2. PROTECTION OF THIRD PARTIES WHO RELY ON MY AGENT. No person who relies in good faith upon any representations by my Agent or Alternate Agent shall be liable to me, my estate, my heirs or assigns, for recognizing the Agent's authority.
3. VALIDITY AND SEVERABILITY. This document is intended to be valid in any jurisdiction in which it is presented. The provisions of this document are separable, so that the invalidity of one or more provisions shall not affect any others. A copy of this document shall be as valid as the original.
4. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
YOU MUST SIGN THIS DOCUMENT IN THE PRESENCE OF TWO WITNESSES AND IN THE PRESENCE OF A NOTARY PUBLIC.
IN WITNESS WHEREOF, I have executed this document this _____ day of ____________________, _____.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
The person who signed this document is of sound mind and voluntarily signed this document in our presence. Each of the undersigned witnesses is at least eighteen years of age and did not sign this document on behalf of or at the direction of .
| Witness Signature: | ________________________________________ |
Date: _________________________
| Witness Signature: | ________________________________________ |
Date: _________________________
STATE OF MISSOURI
COUNTY OF _________________________
On this _____ day of _______________, _____, before me personally appeared , to me known to be the person named in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County of _________________________, State of Missouri, the day and year first above written.
My Commission Expires: ___________________________________
________________________________________
Notary Public
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It's quick and easy to give or receive the support you need using a free Missouri Medical Power of Attorney template from Rocket Lawyer:
This method, in many cases, would be much less time-consuming than finding and hiring a traditional law firm. If necessary, you may start a Medical PoA on behalf of a relative, and then help them sign it once you've drafted it. Please remember that for this document to be legally valid, the principal must be an adult who is mentally competent when they sign. If the principal has already been declared incompetent, a conservatorship generally will be necessary. When dealing with such a scenario, it is best to speak with a lawyer .
Every person over 18 should have a Medical Power of Attorney. Though it can be challenging to think about, there might come a time when you cannot make healthcare decisions on your own. Here are a few common situations where you may find a PoA to be helpful:
Regardless of whether your Missouri Medical Power of Attorney has been drafted as part of a long-term plan or created in response to an emergency, notarization and witnesses are highly encouraged for protecting your agent if anyone disputes their privileges and authority.
At times, in discussing the topics of elder care and estate planning with medical or legal professionals, you might hear "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" being used together or interchangeably. In actuality, they're one and the same. That said, it is possible to get power of attorney over affairs that are not related to medical care, in which case, "proxy" generally is not the term of choice.
Missouri Medical PoA forms are usually simple to make, but you or your agent(s) might still have legal questions. Depending on whom you ask, some lawyers will not even agree to review documents that they did not work on. A more favorable approach would be via attorney services at Rocket Lawyer. As a Premium member, you can ask for guidance from an experienced lawyer or get answers to other legal questions related to your Medical Power of Attorney. As always, Rocket Lawyer is here for you.
The fees associated with working with a law firm to generate a Medical Power of Attorney could be anywhere between $200 and $500. When you use Rocket Lawyer, you aren't just filling out a Power of Attorney template. In case you ever need assistance from a lawyer, your membership provides up to 40% in savings when you hire an attorney.
When you have made your Medical Power of Attorney using Rocket Lawyer, you can open it on any device, anytime. You also can interact with the PoA in all of the following ways: editing it, saving it as a Word or PDF document, printing it out, or signing it. Attached alongside each Power of Attorney form, there's a checklist of tips on what is next to finalize the document. Your agent(s) and care providers should receive copies of the fully executed document.
The specific rules and restrictions governing PoA forms are different by state; however, in Missouri, your document will usually require notarization. If you plan to give an agent authority over your burial or cremation, two witnesses will also need to sign. Finally, as a general principle, your witness(es) should be over 18 years old, and none of them should also be named as your agent.
See Missouri Medical/Healthcare Power of Attorney law: § 404.805
