Mississippi Advance Directive Form

A Mississippi Advance Care Directive, also known as a Living Will Form, is a formal document that is used by an individual to communicate how they would like to end their life, their treatment preferences, and to also choose the medical agents they would like to handle medical decisions when they’re incapacitated. This form is mostly used to prepare individuals for situations where they are incapable of helping themselves in any way. The use of this form is backed up by Title 41, Chapter 41 (Mississippi Health Care Decisions Act).

Mississippi advance directive template

Mississippi Advance Directive Form

To make this document legal, two adults who are recognized in the state of Mississippi are required to imprint their signature on it; these adults can be substituted by a notary public (see § 41-41-209)

This Advance Directive form is divided into:

  1. The Power to elect a person who you would like to act on your behalf with regards to your health care (Known as a Power of Attorney);

  2. The individual's wishes and instructions regarding medical care (Living will).

Part 1: Selecting an agent 

The power to elect a person who you would like to act on your behalf with regards to your health care (Known as a Power of Attorney).

Identifying Elected Health Care Agent 

  1. Enter the name of the health care agent that you would like to be in charge of your medical affairs. It is advisable to take proper care while making this decision as you would be transferring certain decision-making powers to the agent. 

  2. Then, enter the agent’s home/mailing address, followed by their telephone number.

  3. In cases where the health care agent you mentioned earlier is unavailable as a result of certain circumstances, a tab has been opened for you to make mention of a substitute/ alternate agent. 

  4. Enter the home/mailing address of the alternate agent; followed by his/her cell number. 

  5. Select and enter the name of a second alternate health care representative; in case the first alternate agent chosen is unavailable. 

  6. Following this should be the agent’s home/mailing address and phone number in cases where his home address cannot be reached. 

Principal’s Instruction 

  1. In this section, you are to spell out the decisions that your selected health care agent can make on your behalf.

  2. This section of the form states that the health care agent can only begin to make decisions for you when you have been declared (by qualified medical personnel) unable to do this by yourself. Conversely, you can mention a date when you want the agent’s decision-making powers to take effect. 

Guardian Selection 

  1. This is an optional section that can be struck out. Here you are to mention the guardian appointed to you by the court as a health care agent. 

Part 2: The individual's wishes and instructions regarding medical care

Wishes on How Your Life Should End

In the sections that follow. You are to choose between one or the other. 

  1. You can either choose to prolong your life and accept treatments and include facilities like life support that would help extend your lifespan; or

  2. Choose not to prolong your life and request that no treatment that would extend your life be given to you. This is done in cases where you have very little chance of surviving the illness. 

Giving Consent To Receiving Nutrients or Water

  1. In this section, you are to state your opinion on artificial feeding and delivery of water. You are to state whether you would approve of artificial feeding if you are at the point where you are unable to feed properly. If you wouldn't approve of it, you are to leave the tab opened for this purpose empty. 

Pain Relief and Management

  1. This section provides you with the opportunity to state whether or not you want to be relieved of your pain and is also useful in informing your doctors of the medications that you react negatively to. 

Other Desires

  1. In the section that follows, mention any other directions you intend for the selected health care agent to follow. 

Request for Your Physician

This section is optional

  1. In cases where you are indisposed, you can use this section to request that you are cared for by your physician. Make sure to enter the full name of your physician. 

  2. Following this should be his/her house/mailing address.

  3. Also, provide the cell number of the physician mentioned. 

  4. In cases where the mentioned physician is not reachable via all the information you have provided earlier, you must document his/her emergency/office cell number. 

  5. It is also required that you have a substitute physician. In this section, you are to provide necessary information consisting of his/her home address, cell number, etc. 

The Patient’s Signature

  1. In this section, you are to enter the original date this form is filled and completed.

  2. Then, you are required to imprint your signature on the tab opened for it. This is to be done in the presence of two witnesses or before a recognized official. 

  3. Enter your home/mailing address. 


You are required to have two witnesses while imprinting your signature on the document.

  1. The first witness is expected to imprint his signature on the document, and the date entered by him must be the same as the date you entered. 

  2. By signing, he/she affirms that at the time you signed the form, you were of sound mind and not under pressure. He also affirms that he is qualified to make this statement. 

  3. Following this, the witness is required for his name and home/mailing address. 

  4. In the next section, the second witness is to imprint his signature and enter the date he filled the form. 

  5. Following this will be his/her home/mailing address and cell phone number. 

  6. In cases where there are no witnesses, they can be replaced by one recognized legal official ( also known as a notary public) in Mississippi

  7. This official is required to attest to the fact the information on the form was imputed when you were of sound mind.

Download our free Mississippi advance directive in an instant to create a legally binding document.

Download our free Mississippi advance directive in an instant to create a legally binding document.

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