Designation Of Health Care Agent Form - Medical Power Of Attorney Page 3

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MEDICAL POWER OF ATTORNEY
DESIGNATION OF HEALTH CARE AGENT
Advance Directives Act (see §166.164, Health and Safety Code)
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 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:

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