Medical Power of Attorney Texas

 

In order for this document to be valid, it must be signed in the presence of a notary or two witnesses. If you choose to have two witnesses sign, they must be at least 18, competent and independent and not your agent or related to your agent.

MEDICAL POWER OF ATTORNEY

 

1. APPOINTMENT OF HEALTH CARE AGENT

 

I, _______________________________ (Principal’s Full Name) of _____________________________ (Principal’s Street Address), City of _____________________________, State of _________________ (HEREINAFTER known as the “Principal”) hereby appoint, _______________________________ (Agent’s Full Name) of _____________________________ (Agent’s Street Address), City of _____________________________, State of _________________ (HEREINAFTER known as the “Agent”)as my Agent to make any and all medical decisions on my behalf, except to the extent I limit those decisions in this document. This power of attorney takes effect if my doctor certifies in writing that I can no longer make my own health care decisions. My agent can be reached at the following contact information:
 

Home Phone :____________________ Work Phone : ____________________
 

Cell Phone: ____________________ E-Mail: ____________________________

 

2. LIMITATIONS ON MY AGENT

 

My agent is authorized to make all medical decisions on my behalf EXCEPT for the following:

_______________________________________________________________

 

_______________________________________________________________

 

_______________________________________________________________

 

3. APPOINTMENT OF ALTERNATE AGENT

 

If my agent appointed above is unable or unwilling to serve as my agent, I appoint the following person(s) to serve as agents in the order set forth below with the authority to make health care decisions on my behalf as provided herein:

 

1. First Alternate Agent

 

Name: _____________________________________________________

 

Address: ___________________________________________________

 

Phone: _____________________________________________________

 

2. Second Alternate Agent

 

Name: _____________________________________________________

 

Address: ___________________________________________________

 

Phone: _____________________________________________________

 

1. ORIGINAL AND COPIES OF THIS DOCUMENT

 

The original document is/will be filed in the following place:

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

I have/will provided copies of my medical power of attorney to the following:

 

 ________________________________________________________________
 

________________________________________________________________

 

 ________________________________________________________________

 

1. DURATION

 

Unless stated otherwise herein, this document shall remain in effect until I revoke it. I understand that I cannot revoke this document during the time I am considered incompetent to make my own decisions.

 

(If applicable Initial and Check)

 

___________ ☐  (OPTIONAL) This power of attorney shall expire on ____ day

 

of _________________________, 20____.

 

2. PRIOR MEDICAL POWER OF ATTORNEY

 

By signing this document, I hereby revoke any and all prior medical powers of attorney that I may have executed.

1. EXECUTION

 

(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 NOT RELATED BY BLOOD OR MARRIAGE.)

 

SIGNATURES

 

I /We hereby execute this document on ____ day of _____________________, 20____

 

in the City of ________________________, State of _______________.

 

 

Principal’s Signature _____________________ Print Name ______________________

 

Agent’s Signature _____________________ Print Name ______________________

 

1st Alt. Agent’s Signature ____________________ Print Name ___________________

 

2nd Alt. Agent’s Signature ____________________ Print Name ___________________

 

 

NOTARY ACKNOWLEDGMENT

STATE OF __________________

 

__________________ County, ss.

 

On this ____ day of __________________, 20____, before me appeared

 

____________________, as Maker of this Medical Power of Attorney who proved to me through government issued photo identification to be the above-named person, in my presence executed foregoing instrument and acknowledged that (s)he executed the same as his/her free act and deed.

     

_________________________________________

Notary Public 

 

Print Name: _____________________     

 

My commission expires: _____________________

 

 

 

WITNESS STATEMENT AND ACKNOWLEDGMENT:

 

I am not the person appointed as agent or successor agent in this medical power of attorney. I am not related to the maker of this document by blood or marriage. I am not entitled to any portion of the maker's estate, nor do I have any claim against the maker’s estate. I am not the attending physician of the maker or an employee of the attending physician. I am not involved in providing direct patient care to the maker 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 OF FIRST WITNESS

 

Signature: ________________________________________________

         

Print Name: ___________________________________ Date: __________

         

Address: __________________________________________________

 

 

SIGNATURE OF SECOND WITNESS

 

Signature: ________________________________________________

         

Print Name: ___________________________________ Date: __________

         

Address: __________________________________________________