Missouri Medical Power of Attorney Form

The Missouri Medical Power of Attorney Form is a legal document that is provided by a Principal to provide transference of powers to an Agent for the purpose of proving assistance in the determination of medical decisions on behalf of the Principal in the event of incapacitation. This document may also serve as a Health Care Directive, should the Principal decide not to appoint an Agent, to inform health care providers with regard to their wishes.

In completing this document, the Principal may specify when the document will take effect and will have the ability to communicate exactly what they wish regarding their health care. If any of the statements are undesirable to the Principal, they me place an “X” through the entire section or they may strike through specific statements.

The Agent will be expected to follow the instructions exactly as stated by the Principal and always in their best interest. This document will not allow any powers over the Principal’s finances or property.

It would be in the best interest of the Principal to review the entire document prior to completion of this document. If the Principal is unclear with regard to the clarity or language of any portion of the document, they may choose to contact an attorney to be certain that they are properly, legally advised.

How to Write

Step 1 – Download the form – Enter the following information:

  • Print the Principal’s full name
  • Address
  • City, State, Zip Code

Step 2 – Selection of Agent –

  • Enter the name of the Principal
  • Select the county of residence
  • AND
  • Submit the name of the selected Agent
  • Agent’s Complete Address including Zip Code
  • 1st Phone Number
  • 2nd Phone Number
  • AND
  • Enter the name of  up to two Alternate Agents (optional)
  • Alternate Agent(s) Addresses
  • Alternate’s Phone Number(s)
  • Alternate’s 2nd Phone Numbers
  • Read the Titled Section “Durability”

Step 3 –  Effective Date – Principal must read the statements and check one of the following boxes:

  • One physician
  • Two Physicians

Step 4 – Agent’s Powers – Principal must review the statement and initial one of the following boxes:

  • AUTHORIZE the Agent to direct a health care provider to withhold or withdraw artificially supplied nutrition and hydration (including tube feeding of food and water)
  • OR
  • DO NOT AUTHORIZE Agent to direct a health care provider to withhold or withdraw artificially supplied nutrition and hydration (including tube feeding of food and water)
  • Part B of this section – The Principal must initial the line provided if the wish for the Agent to make arrangement for health care services on behalf of the Principal
  • The Principal must carefully review C.D and E

Step 5 – Effective Date as to Other Authority –

  • Principal, read the statement and initial any or all of the powers listed

Step 6 – Organ Donation –

  • Principal must initial the line if they wish to Authorize their Agent to make an anatomical gift of the Principal’s body or part – (organ or tissue)
  • Principal must also check any of the boxes with regard to Anatomical Gifts, as to what and how they wish the donations to occur after death
  • Transplantation
  • Therapy
  • Research
  • Education
  • All the above
  • AND
  • Specify:
  • Any needed organs and tissues, as allowed by law
  • Any needed organs and tissues as allowed by law, with the following restrictions – enter any restrictions
  • Initial the last box in this section if the Principal has decided against Anatomical donations

Step 7 – Health Care Directive – in the Event the Principal decides Against assignment of any Agents:

  • The Principal must review the statement provided and initial the line below if it applies

Step 8 – Persistent Unconsciousness or Incapacitation – In this case, the Principal may select and initial any of the procedures the Principal would wish to approve as follows:

  • Artificially supplied nutrition and hydration (including tube feeding of food and water)
  • Surgery or other invasive procedures
  • Antibiotics
  • Mechanical ventilator (respirator)
  • Radiation therapy
  • Other procedures specified by the Principal (enter any other specified procedures)
  • Heart-lung resuscitation (CPR)
  • Dialysis
  • Chemotherapy
  • All other “life-prolonging” medical or surgical procedures that are merely intended to keep the Principal alive without reasonable hope of improving the Principal’s condition or curing their illness or injury
  • Also review paragraphs 3 and 4

Step 9 – General Provisions Included in the Powers for Health Care and Health Care Directive:

  • The Principal must clearly review this section, If in agreement, initial the line in the left bottom side of the section
  • The Principal must then continue with paragraphs C and D
  • Review the following three sections:
  • Protection of Third Parties Who Rely on The Agent
  • Revocation of Prior Powers for Health Care or Health Care Directive
  • Validity

Step 10 – Signatures – Must be signed before two witnesses and a licensed Notary Public:

  • Submit the printed name of the Principal
  • Signature
  • Printed Name
  • AND
  • Both Witnesses must read the statement and provide the following:
  • Both Witnesses signatures
  • Printed Names
  • Complete addresses
  • AND
  • Notarization –

Once the entire document has been completed the Notary Public will witness all required signatures. The Notary shall then, complete the remainder of the document in acknowledgement, followed by provision of official Missouri State Notary Public Seal