Texas Medical Power Of Attorney Form - Designation Of Health Care Agent
Download a blank fillable Texas Medical Power Of Attorney Form - Designation Of Health Care Agent in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Texas Medical Power Of Attorney Form - Designation Of Health Care Agent with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Texas Medical Power of Attorney Form
Designation of Health Care Agent
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 my physician certifies this fact in
writing.
LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS:
Designation of 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 persons 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 this document is kept at
The following individuals or institutions have signed copies:
Name:
Address:
Phone:
Name:
Address:
Phone:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Medical Certification Of Health Care Provider For Employee's Serious Health Condition Form - Montgomery County Government
Business
Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form
Legal
Related Categories
Parent category: Legal