Medical Power Of Attorney And Texas Will To Live (Page 3 of 8) in pdf

Inform the person who you appoint that you want the person to be your health care agent. Discuss your

instructions and this document with your health care agent in addition to your physician and give each a

signed copy. The document itself should indicate the institutions and people who are in possession of signed

copies.

Your health care 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. You have the right to revoke the authority granted to your health care agent by

informing your health care agent or your health or residential care provider orally or in writing or by

execution of a subsequent Medical Power of Attorney. Unless you state otherwise, your appointment 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 health care agent in the event that your health care agent is unwilling,

unable, or ineligible to act as your health care agent. Any alternate health care agent you designate has the

same authority to make health care decisions for you.

THIS MEDICAL POWER OF ATTORNEY IS NOT VALID UNLESS SIGNED IN THE PRESENCE OF

TWO COMPETENT ADULT WITNESSES. AT LEAST ONE OF THE WITNESSES MUST BE A

PERSON WHO IS NOT ONE OF THE FOLLOWING:

a) the person you have designated as your health care agent,

b) a person related to you by blood or marriage,

c) 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,

d) your attending physician,

e) an employee of your attending physician,

f) an employee of a health care facility in which you are a patient if the employee is providing

direct patient care to you,

g) an officer, director, partner, or business office employee of the health care facility or parent

organization of the health care facility providing care to you, or

h) a person who, at the time this Medical Power of Attorney is executed, has a claim against

any part of your estate after your death.

I have read and understood the contents of this disclosure statement.

(signature)_______________________________________________________________________________

(date)___________________________________________________________________________________

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