TEXAS
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
DISCLOSURE STATEMENT CONCERNING THE DURABLE POWER OF ATTORNEY
FOR HEALTH CARE
A
DURABLE POWER OF A TTORNEY FOR HEALTH CARE IS AN IMPORT ANT LEGAL
DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE
IMPORTANT FACTS:
Except
to the extent you state otherwise, The Durable Power of Attorney for Health Care gives
the person you name as your agent the authority to make any and all health care decisions for you in
accordance with your wishes, including your religious and moral beliefs, when you are no longer capable
of making them yourself. Because "health care" means any treatment, service, or procedure to maintain,
diagnose, or treat your physical or mental condition, your agent has the power to make a broad range of
health care decisions for you. Your agent may consent, refuse to consent, or withdraw a consent to
medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment.
Your agent may not consent to voluntary inpatient mental health services, convulsive treatment,
psychosurgery, abortion, or neglect of the principal through the omission of care primarily intended to
provide comfort. A physician must comply with your agent's instructions or allow you to be transferred to
another physician.
Y
our agent's authority begins when your doctor certifies that you lack the capacity to make health
care decisions.
Y
our agent is obligated to follow your instructions when making decisions on your behalf. Unless
you state otherwise, your agent has the same authority to make decisions about your health care as you
would have had.
I
t is important that you discuss the Durable Power of Attorney for Health Care with your
physician or other health care provider before you sign to make sure that you understand the nature and
range of decisions that may be made on your behalf. If you do not have a physician, you should talk with
someone else who is knowledgeable about these issues and can answer your questions. You do not need a
lawyer's assistance to complete the Durable Power of Attorney for Health Care, but if there is anything
in it that you do not understand, you should ask a lawyer to explain it to you.
T
he person you appoint as agent should be someone you know and trust. The person must be 18
years of age or older or a person under 18 years of age who has had the disabilities of minority removed.
If you appoint your health or residential care provider (e.g., your physician or an employee of a home
health agency, hospital, nursing home, or residential care home, other than a relative), that person has to
choose between acting as your agent or as your health or residential care provider; the law does not permit
a person to do both at the same time.
Y
ou should inform the person you appoint that you want the person to be your health care agent.
You should discuss the Durable Power of Attorney for Health Care with your agent and your physician
and give each a signed copy. You should indicate on the document itself the people and institutions who
have signed copies. Your agent is not liable for health care decisions made in good faith on your behalf.
Nrsg EOL Form #2 Revised: December 26, 2002 Page 1 of 5
Even after you have signed the Durable Power of Attorney for Health Care, you have the right
to make health care decisions for yourself as long as you are able to do so and treatment cannot be given
to you or stopped over your objection. You have the right to revoke the authority granted to your agent by
informing your agent or your health or residential care provider orally or in writing, or by your execution
of a subsequent durable power of attorney for health care. Unless you state otherwise, your appointment
of a spouse dissolves on divorce.
Once
completed, the Durable Power of Attorney for Health Care may not be changed or
modified. If you want to make changes in the document, you must make an entirely new one.
You m
ay wish to designate an alternate agent in the event that your agent is unwilling, unable, or
ineligible to act as your agent. Any alternate agent you designate has the same authority to make health
care decisions for you.
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESENCE
OF TWO OR MORE OUALIFIED WITNESSES. THE FOLLOWING PERSONS MAY NOT
ACT AS WITNESSES:
1. THE PERSON YOU HAVE DESIGNATED AS YOUR AGENT;
2. YO
UR HEALTH OR RESIDENTIAL CARE PROVIDER OR AN EMPLOYEE OF
YOUR HEALTH OR RESIDENTIAL CARE PROVIDER;
3. YOUR SPOUSE;
4. YO
UR LAWFUL HEIRS OR BENEFICIARIES NAMED IN YOUR WILL OR A DEED;
OR
5. CR
EDITORS OR PERSONS WHO HAVE A CLAIM AGAINST YOU.
I have read and
understand the contents of this disclosure statement.
_______________
_________________________ ______________________________________
Signature Date
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DURABLE POWER OF ATTORNEY FOR HEALTH CARE DESIGNATION OF
HEALTH CARE AGENT
I _____________________
____________________________ (Insert your name) appoint:
Nam
e: ___________________________________________________________________
Address: _________________________________________________________________
Phone: ___________________________________________________________________
as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this
document. This durable power of attorney for health care takes effect if I become unable to make my own
health care decisions and this fact is certified in writing by my physician.
LIM
ITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS
FOLLOWS: _________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
DESIGNATION OF ALTERNATE AGENT:
You are not required to designate an alternate agent but you may do so. An alternate agent may
make the same health care decisions as the designated agent, if the designated agent is unable or unwilling
to act as your agent. If the agent designated is your spouse, the designation is automatically revoked by
law if your marriage is dissolved.
If the person designated as my agent is unable or unwilling to make health care decisions for me,
I designate the following persons to serve as my agent to make health care decisions for me as authorized
by this document, who serve in the following order:
A. First Alternate Agent
Nam
e: ___________________________________________________________________
Address: _________________________________________________________________
Phone: ___________________________________________________________________
B. Second Alternate Agent
Nam
e: ___________________________________________________________________
Address: _________________________________________________________________
Phone: ___________________________________________________________________
Re
vised: December 26, 2002 Page 3 of 5
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The original of this document is kept at _____________________________________________________
The following individual or institution has a signed copy of this Directive:
N
ame: ___________________________________________________________________
Address: _________________________________________________________________
_________________________________________________________________
DURATION:
I
understand that this power of attorney exists indefinitely from the date I execute this document,
unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care
decisions for myself when this power of attorney expires, the authority I have granted my agent continues
to exist until the time I become able to make health care decisions for myself. This power of attorney ends
on the following date: (if none, so state) ___________________________________________________ .
P
RIOR DESIGNATIONS REVOKED:
I
REVOKE ANY PRIOR DURABLE POWER OF ATTORNEY FOR HEALTH CARE.
A
CKNOWLEDGMENT OF DISCLOSURE STATEMENT:
I
have been provided with a disclosure statement explaining the effect of this document. I have
read and understand that information contained in the disclosure statement.
(
YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I sign my name to this durable power of attorney for health care on ____ day of _______ , _____
at __________________________________________________________ .
(City and State)
_________
_______________________________ ______________________________________
Print Name Signature
Revised: December 26, 2002 Page 4 of 5
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STATEMENT OF WITNESSES:
I
declare under penalty of perjury that the principal has identified himself or herself to me, that
the principal signed or acknowledged this durable power of attorney in my presence, that I believe the
principal to be of sound mind, that the principal has affirmed that the principal is aware of the nature of
the document and is signing it voluntarily and free from duress, that the principal requested that I serve as
witness to the principal's execution of this document, that I am not the person appointed as agent by this
document and that I am not a provider of health or residential care, or an employee of an operator of a
health care facility.
I declare that I am not related to the principal by blood, marriage, or adoption and that to the best of my
knowledge I am not entitled to any part of the estate of the principal on the death of the principal under a
will or by operation of law.
Wi
tness Signature: _____________________________________________________________________
Print Name: ______________________________________ Date: _______________________________
Address: _____________________________________________________________________________
Witness Signature: _____________________________________________________________________
Print Name: ______________________________________ Date: _______________________________
Address: _____________________________________________________________________________
Revised: December 26, 2002 Page 5 of 5
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