MEDICAL POWER OF ATTORNEY
DESIGNATION OF HEALTH CARE AGENT
Advance Directives Act (see §166.164, Health and Safety
Code)
I, (insert your name) appoint:
Name:
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 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.
LIMITATIONS
ON THE DECISION-MAKING
AUTHORITY
OF MY AGENT ARE
AS
FOLLOWS:
DESIGNATION
OF AN 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 annulled, or declared void unless this
document provides otherwise.)
If the person designated as my agent is unable or unwilling to make health care decisions for
me, I
designate the following person(s) to serve as my agent to make health care decisions for me as
authorized by this document, who serve in the following order:
First Alternate Agent
Name:
Address:
Phone:
Second Alternate Agent
Name:
Address:
Phone:
The
original
of
the
document
is
kept
at
The following individuals or institutions have signed copies:
Name:
Address:
Name:
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.
(IF
APPLICABLE)
This
power
of
attorney
ends
on
the
following
date:
PRIOR
DESIGNATIONS REVOKED
I revoke any prior medical power of attorney.
DISCLOSURE STATEMENT
THIS MEDICAL POWER OF ATTORNEY IS AN IMPORTANT LEGAL DOCUMENT. BEFORE
SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
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 unable to make the decisions
for 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.
Your agent's authority is effective when your doctor certifies that you lack the competence to
make health care decisions.
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 if you were able to make health care decisions for yourself.
It is important that you discuss this document with your physician or other health care provider
before you sign the document to ensure 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.
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 facility, or residential care facility, 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 allow a person to serve as both at the same time.
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 that you intend to
have signed copies. Your agent is not liable for health care decisions made in good faith on
your behalf.
Once you have signed this document, you have the right to make health care decisions for
yourself as long as you are able to make those decisions, 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 in this
document, your appointment of a spouse is revoked if your marriage is dissolved, annulled, or
declared void.
This document may not be changed or modified. If you want to make changes in this document,
you must execute a new medical power of attorney.
You may wish to designate an alternate agent in the event that your agent is unwilling, unable,
or ineligible to act as your agent. If you designate an alternate agent, the alternate agent has
the same authority as the agent 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 medical power of attorney is executed, has a claim against
any part of your estate after your death.
By signing below, I acknowledge that I have read and understand the information contained in
the above disclosure statement.
(YOU MUST DATE AND SIGN THIS POWER OF
ATTORNEY.
YOU MAY SIGN IT AND
HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC OR YOU MAY
SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES.)
SIGNATURE ACKNOWLEDGED BEFORE NOTARY
I sign my name to this medical power of attorney on __________ day of __________
(month, year) at
_____________________________________________
(City and State)
_____________________________________________
(Signature)
_____________________________________________
(Print Name)
State of Texas
County of ________
This instrument was acknowledged before me on __________ (date) by ________________
(name of person acknowledging).
_____________________________
NOTARY PUBLIC, State of Texas
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Notary's printed name:
_____________________________
My commission expires:
____________________________
OR
SI
GNATURE IN PRESENCE OF TWO COMPETENT ADULT WITNESSES
I sign my name to this medical power of attorney on day of (month, year)
at
(City and
State)
(Signature)
(Print
Name)
STATEMENT OF FIRST
WITNESS
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.
Signature:
Print Name: Date: _____________________
Address:
S
IGNATURE OF SECOND
WITNESS
Signature:
Print Name: Date:
Address:
PowerofAttorney.com
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