Disclosure Statement Form For Medical Power Of Attorney (Page 3 of 4) in pdf

Disclosure Statement Form For Medical Power Of Attorney Page 3

Medical Power Of Attorney

Advance Directives Act (see §166.164, Health and Safety Code)

Designation of Health Care Agent:

(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 otherwise

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 certified 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: :

(continued on reverse)

Disclosure Statement Form For Medical Power Of Attorney Page 3