This required section states the name and address of the person appointed to make health care decisions if the Principal is unable to do so. There are limits on who may act as the Agent. Press [Ctrl +F1] for more information.
This required section creates a Durable Power of Attorney for Health Care. It shall be effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for more information.
This is a required section concerning the authority the Agent is given. The Principal grants full power to the Agent to make health care decisions if the Principal is unable to do so. Press [Ctrl+F1] for more information.
This optional section states the Principal's wishes regarding life-prolonging procedures which artificially postpone death. Press [Ctrl+F1] for more information.
This optional section states whether or not the Principal authorizes the Agent to direct withdrawal or withholding of artificially administered food and fluids. Press [Ctrl+F1] for more information.
This optional section gives the Principal the opportunity to include special provisions concerning health care which are not otherwise contained in the document. Press [Ctrl+F1] for more information.
In this optional section the Principal may specify any values or preferences, such as religious beliefs, location of care or personal values, which pertain to this document. Press [Ctrl+F1] for more information.
This optional section enables the Principal to establish specific limitations upon the decision making authority of the Agent. Press [Ctrl+F1] for more information.
This optional section enables the Agent to request, review and disclose information regarding the physical and mental condition of the Principal. Press [Ctrl+F1] for more information.
This optional section gives the Agent the authority to sign on behalf of the Principal if the Principal is unable to do so. Press [Ctrl+F1] for more information.
This required section states whether or not the Agent has authority to make anatomical gifts for medical purposes, authorize an autopsy or direct disposition of remains. Press [Ctrl+F1] for more information.
This required section states the Agent will not incur any financial liabilities while acting as Agent. The Agent may request reimbursement of expenses but will not receive compensation. Press [Ctrl+F1] for more information.
This required section states that this document will become effective upon the certification of one or two physicians that the Principal cannot make decisions for him/herself. Press [Ctrl+F1] for more information.
This is an optional section which states that if the original Agent is not available, an Alternate Agent will assume responsibility of the original Agent. Press [Ctrl+F1] for more information.
In this optional section, the Principal may designate a person to be his/her guardian if one needs to be appointed. Press [Ctrl+F1] for more information.
This required section states that any prior Durable Power of Attorney for Health Care made by the Principal is revoked. Press [Ctrl+F1] for more information.
This required section states that any person or entity who faithfully carries out the terms and provisions of this document shall not be held liable for any damages which may occur. Press [Ctrl+F1] for more information.
This required section states that this document is intended to be valid in any jurisdiction that it is presented. Press [Ctrl+F1] for more information.
This required section states that this document be legally binding and if it is not recognized as a legal document it will be treated as a formal statement of the Principal's desires. Press [Ctrl+F1] for more information.
By signing this required section, the Principal will acknowledge full understanding of the document contents as well as the effects of the granting of powers to the Agent. Press [Ctrl+F1] for more information.
This section requires the signature of two witnesses. The witness statement describes limits on who may act as a witness. Press [Ctrl+F1] for more information.
This section requires the signature of a Notary Public to acknowledge that the Principal signed the document. Press [Ctrl+F1] for more information.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Press [Ctrl+F1] for more information.
Times New Roman
Health Care POA
HCP_MO
The Health Care Power of Attorney is a document under which a competent adult (a Principal), prior to becoming unconscious or incompetent, declares his/her intention that life-sustaining procedures should be withheld or withdrawn under certain circumstances, and designates a person who will have authority to make health care decisions for the Principal, if the Principal is unable to do so.
!!!! !
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Enter the Principal's city or edit the information as desired.
Enter the Principal's state/province or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the Principal's country or edit the information as desired.
HMO01
! Designation of Agent Section (1 of 23)
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
!. DESIGNATION OF AGENT.
I, !, of !, !,
! Country: !,
appoint:
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
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.
NOTE: 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.
This required designation section states the name and address of the person appointed as Health Care Agent. The Agent will make health care decisions for the Principal if the Principal is unable to make such decisions. Press [Ctrl+F1] for more information.
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Enter the Principal's city or edit the information as desired.
Enter the Principal's state/province or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the Principal's country or edit the information as desired.
Enter the Agent's name or use the P.I. Manager to select and paste a record. Note the limits on who may serve as Agent which appear later in this section. The Agent will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
Enter the Agent's street address or edit the information as desired.
Enter the Agent's extended street address or edit the information as desired.
Enter the Agent's city or edit the information as desired.
Enter the Agent's state/province or edit the information as desired. When naming an Agent, consider the availability of the Agent to confer with health care providers and access medical records and information.
Enter the Agent's zip/postal code or edit the information as desired.
Enter an X to include the Agent's country. If the Agent resides in a different country, he/she may not be available to discuss medical decisions with the health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Agent may be reached during non-business hours.
Enter a phone number at which the Agent may be reached during business hours, if different from the home phone number.
Enter the relationship of the Agent to the Principal.
HMO02
! Creation of Durable Power of Attorney for Health Care Section (2 of 23)
!. 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 or incapacitated.
This required section states that a Durable Power of Attorney for Health Care is being created. It shall only be effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for more information.
HMO03
! Authority of Agent Section (3 of 23)
!. 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:
A. Making all necessary arrangements for health care services on my behalf, and to hire and fire medical personnel responsible for my care;
B. 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
C. 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.
This required section states the general duties and powers of the Agent on behalf of the Principal. The health care decisions made by the Agent must be consistent with the desires of the Principal as stated in this document, or otherwise known to the Agent. Press [Ctrl+F1] for more information.
HMO04
! Optional Life-Prolonging Procedures Section (4 of 23)
!. LIFE-PROLONGING PROCEDURES. I encourage my Agent to follow my wishes as expressed in this document in making decisions regarding life-prolonging procedures. However, I have confidence in my Agent's ability to make decisions in my best interest, and I authorize my Agent to make decisions which are contrary to my Directive in his or her best judgment. If my Durable Power of Attorney is somehow determined to be ineffective, or if my Agent is not able to serve, this Directive is intended to be used on its own as firm instructions to my health care providers regarding life-prolonging procedures.
By this Directive I exercise my right to determine the course of my health care and to provide clear and convincing proof of my wishes and instructions about my treatment.
! If I am persistently unconscious or there is no reasonable expectation of my recovery from a seriously incapacitating or terminal illness or condition, I direct that all of the life- prolonging procedures which I have indicated below be withheld or withdrawn.
[You will need to initial this option on the printed document.]
I want the following life-prolonging procedures to be withheld or withdrawn:
! - Surgery or other invasive procedures
! - Heart-lung resuscitation (CPR)
! - Antibiotic
! - Dialysis
! - Mechanical ventilator (respirator)
! - Chemotherapy
! - Radiation therapy
! - All other "life-prolonging" medical or surgical procedures that are merely intended to keep me alive without reasonable hope of improving my condition or curing my illness or injury.
(WRITE YOUR INITIALS ON THE LINE TO THE RIGHT.)
__________________________________
INITIALS
However, if my physician believes that any life-prolonging procedure may lead to a significant recovery, I direct my physician to try the treatment for a reasonable period of time. If it does not improve my condition, I direct the treatment be withdrawn even if it shortens my life. I also direct that I be given medical treatment to relieve pain or to provide comfort, even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit-forming.
Enter an X to include a section concerning the Principal's wishes regarding life-prolonging procedures. States may define this term differently, but generally it means procedures which artificially postpone death. Press [Ctrl+F1] for more information.
Enter an X to specify certain life-prolonging procedures to be withheld or withdrawn if the Principal is permanently unconscious or there is no reasonable expectation of recovery from a serious incapacity or terminal illness.
Enter an X to withdraw or withhold surgery or other invasive procedures if there is no hope of recovery from the above conditions.
Enter an X to withdraw or withhold heart-lung resuscitation if there is no hope of recovery from the above conditions.
Enter an X to withdraw or withhold any antibiotics if there is no hope of recovery from the above conditions.
Enter an X to withdraw or withhold dialysis if there is no hope of recovery from the above conditions.
Enter an X to withdraw or withhold any type of mechanical ventilator (respirator) if there is no hope of recovery from the above conditions.
Enter an X to withdraw or withhold chemotherapy if there is no hope of recovery from the above conditions.
Enter an X to withdraw or withhold any radiation therapy if there is no hope of recovery from the above conditions.
Enter an X to withdraw or withhold all other life-prolonging medical or surgical procedures intended to keep Principal alive if there is no hope of recovery from the above conditions.
HMO05
! Optional Nutrition and Fluids Section (5 of 23)
!. NUTRITION AND FLUIDS.
! I AUTHORIZE MY AGENT 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
! I DO NOT WISH TO AUTHORIZE MY AGENT 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
Enter an X to include a section stating whether or not the Principal authorizes the Agent to direct the withdrawal or withholding of artificially administered nutrition and/or fluids. Note that the Principal needs to initial this provision. Press [Ctrl+F1] for more information.
Enter an X to authorize the Agent to direct the withdrawal or withholding of any artificially supplied nutrition and/or fluids.
Enter an X if the Agent will NOT be authorized to direct the withdrawal or withholding of any artificially supplied nutrition and/or fluids.
IGN06
! Optional Special Provisions Section (6 of 23)
!. SPECIAL PROVISIONS REGARDING MY HEALTH CARE. (For example, describe your wishes regarding any treatment you desire or do not desire, or admission to a residential care facility.)
Enter an X to include a section regarding special provisions concerning health care which are not otherwise contained in the document. For example, describe any types of treatment you wish or wish not to receive. Press [Ctrl+F1] for more information.
Use this space to describe any additional special provisions.
IGN07
! Optional Values and Preferences Section (7 of 23)
!. STATEMENT OF VALUES AND PREFERENCES. (Specify any other wishes, values, religious beliefs, philosophy or other personal values or preferences that are relevant to your instructions. You may also state preferences concerning the location of your care.)
Enter an X to include a section concerning values and preferences about health care. For example, describe values or religious preferences, or the location of treatment. Press [Ctrl+F1] for more information.
Use this space to specify values and preferences.
IAK09
! Optional Limits on Agent's Authority Section (8 of 23)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT:
Enter an X to include a section that allows the Principal to establish limitations on the authority given to the Agent. For example, the Principal may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
Use this space to specify any limits on the Agent's authority to make decisions on behalf of the Principal.
HMO09
! Optional Inspection and Disclosure Section (9 of 23)
!. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my Agent has the power and authority to:
a. Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records;
b. Consent to the disclosure of this information to others.
Enter an X to include a section which enables the Agent to request, review, and disclose any information regarding the physical or mental condition of the Principal. Press [Ctrl+F1] for more information.
HMO10
! Optional Signing Documents Section (10 of 23)
!. SIGNING DOCUMENTS. Where necessary to implement the health care decisions that my Agent is authorized by this document to make, my Health Care Agent has the power and authority to execute on my behalf any of the following:
a. Documents to authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, residential care or assisted living or similar facility or service;
b. Documents titled or purporting to be "Consent to Permit Treatment" or "Refusal to Permit Treatment"; or
c. Any necessary waiver or release from liability required by a hospital or physician.
Enter an X to include a section which gives the Agent the power to sign health care documents (such as admission, discharge, consent, or release forms) on behalf of the Principal. The Agent is NOT responsible for the cost of any medical service provided to the Principal. Press [Ctrl+F1] for more information.
IIL12
! Autopsy, Anatomical Gifts, Disposition of Remains Section (11 of 23)
!. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS.
! I authorize my Agent, to the extent permitted by law,
! I do not authorize my Agent
to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains.
This required section states whether or not the Agent has the authority to make anatomical gifts, authorize an autopsy, and decide upon the disposition of the Principal's remains. Press [Ctrl+F1] for more information.
Enter X if the Agent WILL be authorized to make decisions concerning anatomical gifts, autopsies, and the disposition of the Principal's remains, to the extent permitted by law. Press [Ctrl+F1] for more information.
Enter X if the Agent WILL NOT be authorized to make decisions concerning anatomical gifts, autopsies, and the disposition of the Principal's remains, to the extent permitted by law.
HMO12
! Agent's Compensation Section (12 of 23)
!. 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.
This required section states the Agent is not responsible for the cost of any medical service provided to the Principal. The Agent will not be paid for serving as Health Care Agent, but can request reimbursement of reasonable expenses he/she incurs while acting as Agent. Press [Ctrl+F1] for more information.
HMO13
! Duration Section (13 of 23)
!. EFFECTIVE DATE AND DURABILITY. This Durable Power of Attorney is effective when TWO physicians decide and certify that I am incapacitated and unable to make and communicate a health care decision.
! [If this option is selected, you will need to initial the line below on the printed document.]
I WANT ONE PHYSICIAN INSTEAD OF TWO, TO DECIDE WHETHER I AM INCAPACITATED.
(WRITE YOUR INITIALS ON THE LINE TO THE RIGHT).
__________________________________
INITIALS
This required section states that the power of attorney will become effective when TWO physicians validate that the Principal cannot make decisions for him/herself. An optional provision allows such certification by only ONE physician. Press [Ctrl+F1] for more information.
Enter an X if the Principal wants ONE physician to decide whether
the Principal is incapacitated. The Principal must initial this
option on the printed document. If this selection is not initialed,
the document will not be effective until two physicians certify that
the Principal cannot make decisions for himself/herself.
HMO14
! Alternate Agent Section (14 of 23)
!. ALTERNATE AGENTS. Only an Agent named by me may act under this Durable Power of Attorney. 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 person(s) named below (in the order named if more than one):
FIRST ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
SECOND ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Enter an X to designate an Alternate Agent. If the original Agent resigns or is unable to perform the required duties, an Alternate Agent will assume all responsibilities of the original Agent. Generally, the designation of the Principal's spouse as Agent is revoked upon divorce. Press [Ctrl+F1] for more information.
Enter the Alternate Agent's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Agent's street address or edit the information as desired.
Enter the Alternate Agent's extended street address or edit the information as desired.
Enter the Alternate Agent's city or edit the information as desired.
Enter the Alternate Agent's state/province or edit the information as desired. When naming an Alternate Agent, consider the availability of the Alternate Agent to confer with health care providers.
Enter the Alternate Agent's zip/postal code or edit the information as desired.
Enter an X to include Alternate Agent's country. If the Alternate Agent resides in a different country, consider the availability of the Agent to discuss medical records or information with health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Alternate Agent may be reached during non-business.
Enter a phone number at which the Alternate Agent may be reached during business hours, if different from the home phone number.
Enter an X to include the name of a second Alternate Agent. You do not have to name a second Alternate Agent.
IGN13
! Optional Nomination of Guardian Section (15 of 23)
!. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate
! my Agent (or Alternate Agent)
Name: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
to serve as my Guardian.
Enter an X to include a section that allows the Principal to nominate a person to serve as the Principal's Guardian if one is required by legal proceedings. This person will be appointed if the Court finds that such appointment is in the Principal's best interests. Press [Ctrl+F1] for more information.
Enter an X if the nominated Guardian should be the same person as the appointed Agent or Alternate Agent.
Enter an X if the nominated Guardian will be a person other than the Agent or Alternate Agent.
Enter the Guardian's name or use the P.I. Manager to select and paste a record.
Enter the Guardian's street address or edit the information as desired.
Enter the Guardian's extended street address or edit the information as desired.
Enter the Guardian's city or edit the information as desired. The Guardian will need to be available to act for the Principal.
Enter the Guardian's state/province or edit the information as desired.
Enter the Guardian's zip/postal code or edit the information as desired.
Enter an X to include the Guardian's country, if outside the United States. It is very unlikely that a court would appoint a person living in another country as a Guardian for the Principal.
Enter the country or edit the information as desired.
HMO16
! Revocation Section (16 of 23)
!. REVOCATION. I revoke any prior Durable Power of Attorney for Health Care. 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.
This required revocation section states that all prior Durable Powers of Attorney for Health Care have been revoked. This document may also be revoked by the Principal at any time and in any manner. Press [Ctrl+F1] for more information.
HMO17
! Hold Harmless Section (17 of 23)
!. 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.
This is a required section in which the Principal states that any persons who rely upon any representation by the Agent shall not be liable to the Principal or any interests involved with the Principal. Press [Ctrl+F1] for more information.
HMO18
! Validity Section (18 of 23)
!. VALIDITY. 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.
This required section states that this document and any copies of are intended to be valid in any jurisdiction. Press [Ctrl+F1] for more information.
IGN18
! Statement of Intentions Section (19 of 23)
!. 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.
This required section is a statement of the Principal's desire that the document be legally recognized either as a legal document or a formal statement of the Principal's wishes and desires regarding health care decisions. Press [Ctrl+F1] for more information.
HMO20
! Signature Section (20 of 23)
YOU MUST SIGN THIS DOCUMENT IN THE PRESENCE OF TWO WITNESSES AND IN THE PRESENCE OF A NOTARY PUBLIC. [If this document is not properly witnessed, it may not be enforceable.]
IN WITNESS WHEREOF, I have executed this document this _____ day of _______________, 19___.
________________________________________
Signature
Principal Name: !
Principal Address:City: !
County: ! County
State: !
! Country: !
! SSN: !
This section requires the signature of the Principal in the presence of two witnesses and a Notary Public. If this procedure is not followed, the document may be invalid. Press [Ctrl+F1] for more information.
Enter the Principal's county/parish or edit the information as desired. The other address information was transferred from a previous section and can be modified only by returning to that section.
Enter an X to include the Principal's social security number (SSN). By including the social security number, a health care facility is able to file advance health care directives for future reference. Press [Ctrl+F1] for more information on the Patient Self Determination Act.
Enter the Principal's social security number or edit the information as desired.
HMO21
! Witness Signature Section (21 of 23)
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.
This section requires the signature of two witnesses. By signing this section, the witnesses declare that they were present when the Principal signed this document. Note the limits on who may serve as a witness. Press [Ctrl+F1] for more information.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
HMO22
! Notary Section (22 of 23)
STATE OF MISSOURI
COUNTY OF _________________________
On this _____ day of _______________, 19___, before me personally appeared !, to me known to be the person described 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
This section requires the signature of a Notary Public to acknowledge that the Principal signed this document. The Principal's name was transferred from a previous section and can be modified only by returning to that section.
DOM01
! Health Care Document Information Section (23 of 23)
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record.
The Health Care Power of Attorney should be reviewed:
- if the Agent or the Alternate Agent is no longer able to serve;
- if the Agent is your spouse and you become separated or divorced;
- if you wish to revise your desires as stated in the document.
It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Generally, the Agent, family, and health care provider are given a copy. This section will not print as part of the document. Press [Ctrl+F1] for more information.
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