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Mississippi Advance Health Care Directive (Living Will) Form

The Mississippi advance health care directive(living will) form is a legal document that is designated to serve an individual (Principal/Declarant) who is preparing their medical plans for an end of life situation. The document will allow the Principal to select someone they trust to assist their health care providers with decision-making processes if/when they are no longer able to competently make their own health care decisions. As long as the Principal is of sound mind, they may also revoke or change the information in this document at their own discretion.


Laws – Mississippi Code Title 41, Chapter 41, Sections 201 to 229: Uniform Health-Care Decisions Act

How to Write

Step 1 – The Principal must download the document and begin by reviewing the “explanation” page before they proceed – Once the review is complete begin by designating a Power of Attorney/Agent

  • Enter the name of the Agent into the box at the top of this section
  • Address
  • City
  • State
  • Zip Code
  • Home Telephone number
  • Work Telephone number

Alternate(s) – If the Principal for any reason would relieve the initial agent of their responsibilities they may, in advance, establish up to two more agents by submitting:

  • The name(s) of the alternate agent(s)
  • Address
  • City
  • State
  • Zip Code
  • Home Telephone number
  • Work Telephone number

Agent’s Authority – The Principal must read the entire section –

  • If there are additions to be made, enter them into the lines provided

Step 2 – Instructions for Health Care – If the Principal is comfortable allowing the agent to make all of their decisions for them, they do not need to complete this section, otherwise read the entire section:

  • Check only one box next to the choice that best reflects the wishes of the Principal
  • Read the title -“Artificial Nutrition and Hydration”
  • Relief of Pain – If there are additional instructions they must be entered into the lines provided
  • Other Wishes – If the Principal would like to make additions, enter them into the lines provided

Step 3 – Primary Physician(s) Designation – This section is optional

  • If the Principal would like to designate their primary physicians enter the following for each:
  • Physicians names (respectively)
  • Address
  • City
  • State
  • Zip Code
  • Best telephone contact number
  • Physicians must provide their signatures at the end of this portion of the document

Step 4 – Signatures and Witnesses – The Principal may have the document witnessed by signatures of two unrelated witnesses (the agent may not be a witness) OR the document may be witness by a notary public – Enter the following:

Witnesses – The witnesses must read the witness declarations. If in agreement, submit the following information:

  • Enter the date of witness signatures in mm/dd/yyyy format
  • Witnesses Signatures
  • Printed names
  • Addresses
  • City
  • State
  • OR
  • If the Principal prefers to use a notary, the notary public will witness the document on behalf of the Principal. They shall then complete the notary record and affix the notary seal in acknowledgement

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