Medical Power Of Attorney

Advance Directives Act (see §166.164, Health and Safety Code)
Designation of Health 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 othewvise
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 certitied in writing by my physician.

Limitations On The Decision Making Authority Of My Agent Are As Follows:

________________________________________________________________________

________________________________________________________________________
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 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 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 for me as
authorized by this document, who serve in the following order:

First Alternate Agent

Name: __________________________________________________________________

Address: ________________________________________________________________

___________________________________________Phone: _______________________

Second Alternate Agent

Name: __________________________________________________________________

Address: ________________________________________________________________

__________________________________________Phone: ________________________

The original of the document is kept at __________________________________________

_______________________________________________________________________

The following individuals or institutions have signed copies:

Name:__________________________________________________________________

Address: ________________________________________________________________

_______________________________________________________________________

Name:__________________________________________________________________

Address: :_______________________________________________________________

_______________________________________________________________________

Duration

l understand that this power of attorney exists indefinitely from the date l 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
continues 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.

Acknowledgement of Disclosure 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.

I sign my name to this medical power of attorney on____ day of____________ (month, year)

(City & 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 principaI’s estate on the principaI's death.
I am not the attending physician of the principal or an employee of the attending physician. II have
no claim against any portion of the principals estate on the principaI‘s death. FurthermoreI 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 ofiicer, director, partner, or business oftice
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:_____________________________________________________________________

version 10/25/99