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Fillable Printable Medical Power of Attorney And Disclosure Statement - Texas

Fillable Printable Medical Power of Attorney And Disclosure Statement - Texas

Medical Power of Attorney And Disclosure Statement - Texas

Medical Power of Attorney And Disclosure Statement - Texas

Medical Power of Attorney And Disclo sure Statement Page 1
INFORMATION CONCERNING
THE MEDICAL POWER OF ATTORNEY
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 m ake
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 m ental
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 perm it 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.
MEDICAL POWER OF AT TORNEY AN D DISCLOSURE STAT EMENT PAGE 2
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.
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:
(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.
Medical Power of Attorney And Disclo sure Statement Page 3
MEDICAL POWER OF ATTORNEY
DESIGNATION OF HE ALTH 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 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 m arriage is dissolved.)
If the person designated as my agent is unable or unwilling to make health care decisio n s
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
Name:________________________________________
Address:_____________________________________
Phone__________________________________
B. Second Alternate Agent
Name:________________________________________
Address:_____________________________________
Phone__________________________________
The original of this document is kept at:
MEDICAL POWER OF AT TORNEY AN D DISCLOSURE STAT EMENT PAGE 4
______________________________________________________
______________________________________________________
______________________________________________________
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 contin ues 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.
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.
(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).
Medical Power of Attorney And Disclo sure Statement Page 5
_________________________________________________________ (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
Notary’s printed name: ___________________
My commission expires: __________________
OR
SIGNATURE 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:__________________________________________________
SIGNATURE OF SECOND WITNESS.
Signature:________________________________________________
Print Name:___________________________________ Date:______
Address:__________________________________________________
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