Mississippi Living Will Form | Advance Health Directive

The Mississippi Living Will, also called Health Care Directive form allows the principal to legally choose the medical treatment they would want should they become incapacitated or irrational and unable to make these choices. This document requires attestation by two (2) witnesses or a notary public in accordance with § 41-41-209.

How to Write

Power Of Attorney Health Care: Part One

1) Designation Of Agent

Details of the agent and any alternative agents must be entered.

  • Agent`s name.
  • Agent`s address and ZIP code.
  • Agent`s home and work telephone numbers.


2) Agent`s Authority

The principal must enter details regarding the agent`s authority over their end of life care.


Instructions For Health Care: Part 2

6) End Of Life Decisions

The principal must check the relevant boxes to denote the types of end of life care and treatments they require.

  • Check box not to prolong life.
  • Check box to prolong life.


7) Artificial Nutrition And Hydration

The principal must check the box to provide artificial hydration and nutrition in all situations.


8) Relief From Pain

The principals must describe any exceptions they might require regarding the provision of pain relief.


9) Other Wishes

The principal must enter details of any other wishes or instructions they have regarding their health care and treatment.


Primary  Physician: Part 3

10) Designation Of Physician

The details of the physician and any alternative physicians designated to administer the primary health care of the principal must be entered.

  • Physician`s name.
  • Physician`s address and ZIP code.
  • Physician`s telephone number.


12) Signatures.

The principal must enter their personal details.

  • Date.
  • Address.
  • Printed name.
  • Signature.


13) Witnesses

The details of witnesses / notary`s must be entered.

  • Date.
  • Address.
  • Printed name.
  • Signature.
  • State of notary.
  • County of notary.
  • Date.
  • Name of notary.
  • Name of principal.
  • Signature of notary.
  • Expiration date of notary`s commission.