Mississippi Living Will
This Living Will is designed in accordance with the Mississippi Health Care Decisions Act and allows you to express your wishes regarding medical treatment in the event that you are unable to communicate your decisions due to illness or incapacity.
Please complete the following information:
Full Name: ___________________________________
Date of Birth: ________________________________
Address: _____________________________________
City: ___________________ State: MS Zip: ________
Phone Number: _______________________________
Designation of Health Care Surrogate
In the event that I am unable to make my own health care decisions, I designate the following individual as my Health Care Surrogate to make decisions on my behalf:
Name: _______________________________________
Relationship: ________________________________
Address: _____________________________________
Phone Number: _______________________________
Alternate Surrogate (if primary is unavailable):
Name: _______________________________________
Relationship: ________________________________
Address: _____________________________________
Phone Number: _______________________________
Living Will Declarations
I, ________________________ (insert your name), being of sound mind, hereby make the following declarations with respect to my health care treatment in the event I become unable to make my own decisions:
- I do wish/do not wish (circle one) to receive life-sustaining treatment if I am in a terminal condition and the use of such treatment would only serve to artificially prolong the process of dying, or if I am in a state of permanent unconsciousness.
- I do wish/do not wish (circle one) to receive nutrition and hydration provided by medical means if I am unable to take food or water by mouth.
- Specific instructions about my health care treatment preferences, if any: ________________________________________________________________________________
Organ Donation
I do/do not (circle one) wish to donate any needed organs or tissues at the time of my death.
Signature and Date
I understand that this living will represents my wishes concerning my health care. I am emotionally and mentally competent to make these decisions.
Signature: _______________________________ Date: ________________
Witness: _________________________________ Date: ________________
Address of Witness: _____________________________________________
Notarization (if applicable)
This document was acknowledged before me on (date) _______________ by (name of declarant) ________________________________.
Notary Public: ____________________________
My commission expires: ____________________