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Mississippi Advance Health-Care Directive Form

Names a medical agent, with an optional immediate-authority choice; otherwise the primary physician’s incapacity determination activates authority.

Jurisdiction
Mississippi
Purpose
Medical & health care
Source / form version
No revision date printed; university-hosted file path dated January 2025.
Resource format
PDF
Signing
Date and sign, then use two qualified adult witnesses OR acknowledgment before a notary. The witness declarations include relationship, inheritance, agent, and care-provider restrictions.
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Sources checked: 2026-11-13. General information, not individual legal advice.

Use the health care appointment in Part 1

The university’s advance directive combines a health care power of attorney, treatment instructions, and designation of a primary physician. Part 1 names the agent and two possible alternates. Read the limitations on who may serve, particularly if considering someone involved in providing or operating your current care.

Sources: [1] [2]

Choose timing and instructions deliberately

The form ordinarily activates the agent’s authority when the primary physician determines that you cannot make your own health care decisions. It also has an option for immediate authority. Part 2 addresses health care wishes, including life-prolonging care and relief of suffering. Complete only the parts you intend to use, while keeping the instructions consistent.

Sources: [1] [2]

Finish one execution method

The form asks for the principal’s dated signature and either two qualified adult witnesses or notarization. If using witnesses, read both declarations: the agent and specified care-provider personnel cannot witness, and one witness must satisfy the additional unrelated and non-beneficiary requirement. Provide the complete signed directive to the agent, alternates, physician, and other providers who may need it.

Sources: [1] [2]

Common questions

Can I use this only to name an agent?

The instructions allow all or part of the form to be used. Complete the health care appointment and execution requirements if that is the function you need.

Sources: [1] [2]

Is this the same as a financial durable POA?

No. The document addresses health care decisions. Authority over banking, property, or business affairs requires an appropriate separate financial appointment.

Sources: [1] [2]

Related forms and guides

Sources and verification

  1. Mississippi State University Health Center: source and instructions (opens in a new tab)
  2. Mississippi official law access (opens in a new tab)

HTTP200; seven pages,37 interactive fields. Actual form and witness/notary alternatives inspected. No claim that the university updated the legal text inJanuary2025; that is only the file-path date. MSU Extension olderURL404, avoided.

The date above records a source check. It does not certify that a form is suitable for your circumstances or that an attorney has reviewed your document. Read the publisher’s current instructions before use.