Designation Of Health Care Agent Form - Medical Power Of Attorney printable pdf download

Disclosure Statement for Medical Power of Attorney

Advance Directives Act (see §166.163, Health and Safety Code)

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 name 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 no longer capable of making them yourself. Because "health

care" means any treatment, service or procedure 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 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 comply with

your 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 competence 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 care provider before you

sign it to make sure 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 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 older 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 physician or an employee of a home health

agency, hospital, nursing home, or residential care home, other than a relative), that person has to choose

between acting as your agent or as your health 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 signed 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.

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 and treatment cannot be given to you or 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 in writing or by your execution of a subsequent medical power of

attorney. Unless you state otherwise, your appointment of a spouse dissolves on divorce.

Designation Of Health Care Agent Form - Medical Power Of Attorney