Designation Of Health Care Agent Form - Medical Power Of Attorney (Page 4 of 5) in pdf

Designation Of Health Care Agent Form - Medical Power Of Attorney Page 4

DURATION

I understand that this power of attorney exists indefinitely from the date I execute this document unless I establish a

shorter time or revoke the power of attorney. If I am unable to make health care decisions for myself when this

power of attorney expires, the authority I have granted my agent continues to exist until the time I become able to

make health care decisions for myself.

(IF APPLICABLE) This power of attorney ends on the following date:

PRIOR DESIGNATIONS REVOKED

I revoke any prior medical power of attorney.

ACKNOWLEDGEMENT 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 POWER OF ATTORNEY. YOU MAY

SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A

NOTARY PUBLIC OR YOU MAY SIGN IT IN THE PRESENCE OF TWO

COMPETENT ADULT WITNESSES.)

SIGNATURE ACKNOWLEDGED BEFORE NOTARY

I sign my name to this medical power of attorney on

day of

(month, year) at

(City and State)

(Signature)

(Print Name)

State of Texas

County of

This instrument was acknowledged before me on

(date) by

(name of person acknowledging).

NOTARY PUBLIC, State of Texas

Notary's printed name:

My commission expires:

Designation Of Health Care Agent Form - Medical Power Of Attorney Page 4