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

Medical Power Of Attorney And Texas Will To Live Page 8

ACKNOWLEDGMENT OF DISCLOSURE STATEMENT

I have been provided with a disclosure statement explaining the effect of this document. I have read and

understand that information contained in the disclosure statement.

(YOU MUST DATE AND SIGN THIS MEDICAL POWER OF ATTORNEY.)

I Sign My Name to this Medical Power of Attorney on

this _________ Day of ______________, 20_____

at ___________________________________ (City, State).

(Your Signature)__________________________________________________________________________

(Your Printed Name)_______________________________________________________________________

STATEMENT OF WITNESSES

I am not the person appointed as health care 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 principal's estate on the principal's death. I

am not the attending physician of the principal or an employee of the attending physician. I have no claim

against any portion of the principal's estate 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.

First Witness Signature:_____________________________________________________________________

Name:___________________________________________________________________________________

Date:____________________________________________________________________________________

Residential Address: _______________________________________________________________________

Second Witness Signature: __________________________________________________________________

Name:___________________________________________________________________________________

Date:____________________________________________________________________________________

Residential Address: _______________________________________________________________________

Page 8 of 8

Medical Power Of Attorney And Texas Will To Live Page 8