Fillable Printable Medical Power of Attorney Form - Texas

Medical Power of Attorney Form - Texas

TEXAS MEDICAL POWER OF ATTORNEY

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 healthcare decisions for you in accordance with your wishes, including

your religious and moral beliefs, when you are no longer capable of making them for yourself.

Because “healthcare” 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 healthcare 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 impatient 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

healthcare 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 healthcare as

you would have had.

It is important to discuss this document with your physician or other healthcare 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 take 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 a person under 18 years of age who has had the disabilities of minor 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 healthcare 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 healthcare decisions make in good faith on your behalf.

Even after you have signed this document, you have the right to make healthcare 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

healthcare decisions for you.

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THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESCENCE

OF TWO COMPETENT ADULT WITNESSES. THE FOLLOWING PERSONS MAY NOT ACT

AS ONE OF THE WITNESSES:

1) the person you have designated as your agents; 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 healthcare 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 healthcare facility or of

any parent organization of the healthcare 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.

I have read and understood the contents of this disclosure statement.

(Signature)_______________________________________ (Date) _____________________

DESIGNATION OF HEALTHCARE AGENT

I, ________________________________________________ (insert your name) appoint:

_________________________________________________________________________

Name

_________________________________________________________________________

Address Telephone

As my agent to make any and all healthcare 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 healthcare decisions and this fact is certified in writing by my physician.

LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS

FOLLOWS:

_______________________________________________________________

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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 healthcare 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 healthcare decisions for me, I

designate the following persons to serve as my agent to make healthcare decisions for me as authorized

by this document, who serve in the following order:

A. First Alternate Agent

_____________________________________________________________

Name

_____________________________________________________________

Address Telephone

B. Second Alternate Agent

_____________________________________________________________

Name

_____________________________________________________________

Address Telephone

LOCATION OF DOCUMENT

The original document is kept at: _____________________________________________

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 healthcare 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

healthcare issues for myself.

(IF APPLICABLE) This power of attorney ends on the following date: ______________

PRIOR DESIGNATION REVOKED

I revoke any prior Medical Power of Attorney.

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ACKNOWLEDGMENT OF DISCLOSURE STATEMENT

I have been provided with a Disclosure Statement explaining the effect of this document.

I have read and understood that information contained in the Disclosure Statement.

PRINCIPAL SIGNATURE

(You must date and sign this power of attorney)

I sign my name to this medical power of attorney on _____________ day of

___________, 20______, at ________________________________________

(City and State)

____________________________________ _____________________________

(Signature) (Print Name)

____________________________________________ ______________________

(Address) (Date of Birth)

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 healthcare 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

healthcare facility or of any parent organization of the healthcare facility.

Signature: ____________________________________________________________

Print Name: __________________________________ Date: ___________________

Address: _____________________________________________________________

SIGNATURE OF SECOND WITNESS

Signature: ____________________________________________________________

Print Name: __________________________________ Date: ___________________

Address: _____________________________________________________________

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