Fill and Sign the Texas Health Care Form

Medical Power of Attorney Page 1 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 nam e as your agent the authority to make any and all health care decisions for you in accordance wit h your wishes, including your religious and moral beliefs, when you are no longer capable of maki ng them yourself. Because "health care" means any treatment, service, or proc edure 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 decis ions about withdrawing or withholding life- sustaining treatment. Your agent may not consent to voluntary inpatient mental healt h services, convulsive treatment, psychosurgery, or abortion. A physician must comply with y our 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 com petence 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 make decisions about your health care as you would have had. It is important that you discuss this document with your physician or other health ca re provider before you sign it to make sure that you understand the nature and range of decisions t hat 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 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 olde r 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 phy sician or an employee of a home health agency, hospital, nursing home, or residential care home, other t han a relative), that person has to choose between acting as your agent or as your hea lth 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 si gned copy. You should indicate on the document itself the people and institutions who have signed copies. Your agent is not liable for health care decisions made in good faith on your behalf. MEDICAL POWER OF ATTORNEY AND DISCLOSURE STATEMENT PAGE 2 Even after you have signed this document, you have the right to make health care decis ions for yourself as long as you are able to do so and treatment cannot be given to you or stopped ov er your objection. You have the right to revoke the authority granted to your agent by infor ming 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 appo intment 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 un willing, unable, or ineligible to act as your agent. Any alternate agent you designate has the sa me authority to make health care decisions for you. THIS POWER OF ATTORNEY IS NOT VALID UNLESS: (1) YOU SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC; OR (2) YOU SIGN IT IN 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 marriage; (3) a person entitled to any part of your estate after your death under a will or c odicil executed by you or by operation of law; (4) your attending physician; (5) an employee of your attending physician; (6) an employee of a health care facility in which you are a p atient if the employee is providing direct patient care to you or is an officer, director, partner, or business offic e employee of the health care facility or of any parent organization of the health care facility; or (7) a person who, at the time this po wer of attorney is executed, has a claim against any part of your estate after your death. Medical Power of Attorney Page 3 MEDICAL POWER OF ATTORNEY 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 s tate otherwise in this document. This medical power of attorney takes effect if I be come unable to make my own health care decisions and this fact is certified in writing by my phy sician. LIMITATIONS ON THE DECISION -MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS: _______________________________________________________________ _______________________________________________________________ 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 health care decisions as the designated agent if the designated a gent 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 , annulled, or declared void unless this document provides otherwise.) If the person designated as my agent is unable or unwilling to make health care de cisions for me, I designate the follo wing persons to serve as my agent to make health care decisions for me as authorized by this document, who serve in the following order: A. First Alternate Agent Name: _____________________________________________ Address: _____________________________________________ Phone: _____________________________________________ MEDICAL POWER OF ATTORNEY AND DISCLOSURE STATEMENT PAGE 4 B. Second Alternate Agent Name: _____________________________________________ Address: _____________________________________________ Phone: _____________________________________________ The original of this document is kept at: _____________________________________________ _____________________________________________ _____________________________________________ The following individuals or institutions have signed copies: Name: _____________________________________________ Address: _____________________________________________ _____________________________________________ Name: _____________________________________________ Address: _____________________________________________ _____________________________________________ 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 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. Medical Power of Attorney Page 5 DISCLOSURE STATEMENT. THIS MEDICAL POWER OF ATTORNEY 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 nam e 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 un able to make the decisions for yourself. Because "health care" means any treatment, servi ce, or procedure to maintain, diagnose, or treat your physical or mental condition, your agent has the powe r to make a broad range of health care decisions for you. Your agent may consent, refuse to conse nt, or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life -sustaining treatment. Your agent may not consent to voluntary inpatient mental health services, convulsive treatment, psychosurgery, or abortion. A physician must c omply with your agent's instructions or allow you to be transferred to another physician. Y our agent's authority is effective when your doctor certifies that you lack the com petence to make health care dec isions. 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 decis ions about your health care as you would have if you were able to make health care decisions for yourself. It is important that you discuss this document with your physician or other healt h care provider before you sign the document to ensure 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 tal k 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 i n 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 older or a person under 18 years of age who has had the disabiliti es 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 facility, or residentia l care facility, other than a relative), that person has to choose between acting as your agent or as your he alth or residential care provider; the law does not allow a person to serve as both at t he 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 itself the people and institutions that you intend to have signed copies. Your agent is not liable for health care decisions made in g ood faith on your behalf. Once you have signed this document, you have the right to make health care decisions for yourself as long as you are able to make those decisions, and treatment cannot be given to you or MEDICAL POWER OF ATTORNEY AND DISCLOSURE STATEMENT PAGE 6 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 i n writing or by your execution of a subsequent medical power of attorney. Unless you state otherwis e in this document, your appointment of a spouse is revoked if your marriage is dissolved, annulled, or declared void. This document may not be changed or modified. If you want to make changes in this document, you must execute a new medical power of attorney. You may wish to designate an alternate agent in the event that your agent is unwil ling, unable, or ineligible to act as your agent. If you designate an alternate age nt, the alternate agent has the same authority as the agent to make health care decisions for yo u. THIS POWER OF ATTORNEY IS NOT VALID UNLESS: (1) YOU SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC; OR (2) YOU SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES. THE FOLLOWING PER SONS 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 marriage; (3) a person entitled to any part of your estate after your death und er 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 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 off ice employee of the health care facility or of any parent organization of the health care facility; or (7) a person who, at the time this m edical power of attorney is executed, has a claim against any part of your estate after your death. By signing below, I acknowledge that I have read and understand the information c ontained in the above disclosure statement. Medical Power of Attorney Page 7 (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. ) SIGNATURE ACKNOWLEDGED BEFORE NOTARY I sign my name to this medical power of a ttorney on _______ day of __________________ (month, year) at _____________________________ (City and State). _________________________________________________________ (Signature) _____________________________________________ (Print Name) State of Texas County of ___________ This instrument was acknowledged before me on ____________________ _(date) by _____________________________ (name of person acknowledging). _________________________________________ NOTARY PUBLIC, State of Texas Notary’s printed name: ___________________ My commission expires: __________________ OR SIGNATURE IN PRESENCE OF TWO COMPETENT ADULT WITNESSES I sign my name to this medical power of attorney on _______ day of __________________ (month, year) at _____________________________ (City and State). _________________________________________________________ (Signature) _____________________________________________ (Print Name) MEDICAL POWER OF ATTORNEY AND DISCLOSURE STATEMENT PAGE 8 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 principa l's estate on the principal's death. I am not the attending physician of the principal or an employee of t he attending physician. I have no claim against any portion of the principal's e state on the principal's death. Furthermore, 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 officer, director, partner, or business office 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: _____________________________________________