Fillable Printable 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: __________________

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:__________________________________________________