Disclosure Statement for Medical Power of Attorney

Advance Directives Act (see §166.163, Health and Safety Code)

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 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
withdrawing or withholding life­sustaining treatment. Your agent may not consent to
voluntary inpatient mental 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 certitìes 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 rnake 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 Iawyer‘s assistance to complete this document, but if there
is anything in this document that you do not understandI 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 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. You should discuss this document with your agent and your physician and give
each a signed copy. You should indicate on the document the people and institutions
who have signed copies. Your agent 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 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, by your execution of a subsequent medical power of attorney. Unless you state
otherwise, your appointment of a spouse dissoives on divorce.

This document may not be changed or modifled. 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,
unableI or ineligible to actas 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 in the presence of two competent
adult witnesses. The following persons may not act as ONE of the witnesses:
- the person you have designated as your agent. 
- a person related to you by blood or marriage; 
- 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;
- your attending physician;
- an employee of your attending physician;
- 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 otiicer, director, partner, or business
ortice employee of a health care facility or of any parent organization of the health
care facility; or
- a person who, at the time this power of attorney is executed, has a claim against any
part of your estate after your death.