Fillable Texas Medical Power Of Attorney

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Texas Medical Power Of Attorney

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  • 62 other fields

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File type: PDF

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State of Texas
MEDICAL POWER OF ATTORNEY
1. DESIGNATION OF HEALTH CARE AGENT. I, ________________________, appoint:
Agent’s Name
Agent’s Address
City
State
Zip Code
Agent’s Telephone
as my agent to make any and all health care decisions for me, except to the extent I state otherwise in
this document. This Medical Power of Attorney takes effect if I become unable to make my own health
care decisions and this fact is certified in writing by my physician.
2. DESIGNATION OF ALTERNATE AGENT. 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 mak
e
heal
th care decisions for me as authorized by this document, who serve in the following order:
First Alternate Agent
First Alternate Agent’s Name
First Alternate Agent’s Address
City
State
Zip Code
First Alternate Agent’s Telephone
Second Alternate Agent
Second Alternate Agent’s Name
Second Alternate Agent’s Address
City
State
Zip Code
Second Alternate Agent’s Telephone
3. LIMITATIONS ON THE DECISION-MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS:
____________________________________________________________________________________
4. LOCATION OF COPIES. The original of this document is kept at: _____________________________
____________________________________________________________________________________
The following individuals or institutions have signed copies:
Name: ________________________
Address: ________________________________________
Name: ________________________
Address: ________________________________________
Name: ________________________
Address: ________________________________________
5. DURATION. I understand that this power of attorney: (Check one)
☐ Exists indefinitely from the date I execute this document
☐ Ends on _______________, 20_____
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.
6. PRIOR DESIGNATIONS REVOKED. I revoke any prior medical power of attorney.
7. ACKNOWLEDGMENT 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.
8. SIGNATURES.
I sign my name to this medical power of attorney on _____ day of _______________, 20_____ at
_________________ [City], _________________ [State].
Principal's Signature
Principal's Full Name
Principal Address
City
State
Zip Code
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signature
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NOTARY ACKNOWLEDGMENT
State of _________________
County of _________________
This instrument was acknowledged before me on _______________ (date) by
________________________ (name of person acknowledging).
________________________________
NOTARY PUBLIC, State of _________________
Notary’s printed name: ________________________
My commission expires: __________________
STATEMENT OF YOUR WITNESSES
I am not the person appointed as agent by this document. I am not related to the principal by blood or
marriage. I would not be entitled to any portion of the principal's estate on the principal's death. I am not
the attending physician of the principal or an employee of the attending physician. I have no claim against
any portion of the principal's estate on the principal's death. Furthermore, if I am an employee of a health
care facility in which the principal is a patient, I am not involved in providing direct patient care to the
principal and am not an officer, director, partner, or business office employee of the health care facility or
of any parent organization of the health care facility.
First Witness
Witness Signature
Witness Name
Witness Address
City
State
Zip Code
Second Witness
Witness Signature
Witness Name
Witness Address
City
State
Zip Code
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signature
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signature
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DISCLOSURE STATEMENT
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD
KNOW THESE IMPORTANT FACTS:
1. Except to the extent you state otherwise, this document 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 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, or abortion. A physician must comply with
your agent's instructions or allow you to be transferred to another physician.
2. Your agent's authority begins when your doctor certifies that you lack the competence to make health
care decisions.
3. Your 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.
4. It is important that you discuss this document with your physician or other health care provider before
you sign it 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 this
document, but if there is anything in this document that you do not understand, you should ask a lawyer
to explain it to you.
5. The 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.
6. You should inform the person you appoint that you want the person to be your health care agent. You
should discuss this document 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.
7. Even after you have signed this document, 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 medical
power of attorney. Unless you state otherwise, your appointment of a spouse dissolves on divorce.
8. This document may not be changed or modified. If you want to make changes in the document, you
must make an entirely new one.
9. You may 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
1. You sign it and have your signature acknowledged before a notary public; or
2. You sign it in the presence of two competent adult witnesses.
THE FOLLOWING PERSONS MAY NOT ACT AS ONE OF THE WITNESSES
1. The person you have designated as your agent;
2. A person related to you by blood or marriage;
3. A person entitled to any part of your estate after your death under a will or codicil executed by you or
by operation of law;
4. Your attending physician;
5. An employee of your attending physician;
6. An employee of a health care facility in which you are a patient if the employee is providing direct
patient care to you or is an officer, director, partner, or business office employee of the health care facility
or of any parent organization of the health care facility; or
7. A person who, at the time this power of attorney is executed, has a claim against any part of your
estate after your death.
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Texas Medical Power Of Attorney

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Completed 12 February 2022

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