Fillable Printable Disclosure Statement for Medical Power of Attorney

Disclosure Statement for Medical Power of Attorney

Advance Directives Act (see §166.163, Health and Safety Code)

This 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 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.

Your agent's authority begins 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 had.

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.

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.

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.

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, by your execution of a subsequent medical power of attorney. Unless you state

otherwise, your appointment of a spouse dissolves on divorce.

This document may not be changed or modified. If you want to make changes in the

document, you must make an entirely new one.

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 it is signed in the presence of two competent

adult witnesses. The following persons may not act as ONE of the witnesses:

• the person you have designated as your agent.

• a person related to you by blood or marriage;

• 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;

• your attending physician;

• an employee of your attending physician;

• 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 a health care facility or of any parent organization of the health

care facility; or

• a person who, at the time this power of attorney is executed, has a claim against any

part of your estate after your death.

Medical Power Of Attorney

Advance Directives Act (see §166.164, Health and Safety Code)

Designation of Health Care Agent:

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.)

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: :

(continued on reverse)

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.

Acknowledgement of Disclosure Statement

I have been provided with a disclosure statement explaining the effect of this document. I have

read and understand the information contained in this disclosure statement.

(You Must Date and Sign This Power of Attorney)

I sign my name to this medical power of attorney on

day of

(month, year)

(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:

Signature of Second Witness

Signature:

Print Name: Date:

Address:

version 10/25/99