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Texas _______________________ Page 3 ______________________________________________ Print Name: _____________________________________________________________ Date: ______________________ Address: __________________________________________________________________________________ Date: ______________________ Address: ________________________________________________________________ Signature of Second Witness Signature: ________________ employee of the health care facility or of any parent organization of the health care facility. Signature: _______________________________________________________________ Print Name: ________________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 officenot 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 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 (City and State) (Signature) ____________________________________________________________ (Print Name) ___________________________________________________________ Statement of First Witness I am not and Sign This Power of Attorney) Page 2 I sign my name to this medical power of attorney on _____________ day of _________ (month, year) at _________________________________________________________,ure 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 Datens 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 Disclosm 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 decisio__________________ 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 adress: ________________________________________________________________ Name: __________________________________________________________________ Address: ____________________________________________________________________________________________________________ The following individuals or institutions have signed copies: Name: __________________________________________________________________ Ad_______________________________________ Phone: ________________________________________________________________ The original of the document is kept at _______________________________________ ________ Second Alternate Agent Name: _________________________________________________________________ Address: _______________________________________________________________ ________________________________________________________________________________ ______________________________________________________________________ Phone: ________________________________________________________________ Page 1 decisions for me as authorized by this document, who serve in the following order: First Alternate Agent Name: _________________________________________________________________ Address: ______________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 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 ___________________________________________ 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 careMy Agent Are As Follows: ________________________________________________________________________ ________________________________________________________________________ _____________________________s 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 _____ Phone: ________________________________________________________________ as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. Thi_____________________________________________________________ Address: _______________________________________________________________ _________________________________________________________________ate after your death. Page 2 TEXAS MEDICAL POWER OF ATTORNEY FOR HEALTH CARE Designation of Health Care Agent: I, _____________________________________________ (insert your name) appoint: Name: ____yee 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 estng 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 emploarriage; (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 attendiIN 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 mng, 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 ent 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 unwillial 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. Page 1 This docum 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 residentint 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 areYou 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 ageyour 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. er (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 ou 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 providtance 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 yat 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 assisould 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 thour 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 wth 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. Yhdrawing or withholding lifesustaining treatment. Your agent may not consent to voluntary inpatient mental health services, convulsive treatment, psychosurgery, or abortion. A physician must comply win, 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 witmoral 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 conditioyou 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 Disclosure Statement for Texas Medical Power of Attorney for Health Care This is an important legal document. Before signing this document, you should know these important facts: Except to the extent Texas