Official Texas Medical Power of Attorney Document

Texas Medical Power of Attorney

This document grants authority to a designated individual to make medical decisions on behalf of the principal (the person creating the Medical Power of Attorney) as allowed under the Texas Health and Safety Code, Chapter 166. This authority comes into effect only when the principal is unable to make their own medical decisions.

Principal's Information

• Full Name: ________________________
• Address: ________________________
• City, State, Zip: ________________________
• Phone Number: ________________________
• Date of Birth: ________________________

Agent's Information

• Full Name: ________________________
• Relationship to Principal: ________________________
• Address: ________________________
• City, State, Zip: ________________________
• Phone Number: ________________________
• Alternate Phone Number: ________________________

In accordance with the Texas Health and Safety Code, the above-named individual is hereby appointed as my Medical Power of Attorney, also known as my health care agent, to make health care decisions on my behalf should I become unable to participate in my own care. Decisions made by this agent will adhere to any instructions I provide while I am capable of doing so.

Scope of Authority

The agent's power includes, but is not limited to, the ability to:

1. Consent to, refuse, or withdraw consent for any type of medical treatment or procedure, even if life sustaining.
2. Make decisions about the use of artificially administered nutrients and hydration (food and water).
3. Admit or discharge the principal from any type of health facility.
4. Access medical records and disclose them to others where necessary.
5. Decide about autopsy and organ donation.

The agent's authority does not commence until the principal's attending physician certifies in writing that the principal lacks the ability to make informed health care decisions.

Signatures

This document must be signed by the principal, in the presence of two witnesses or a notary public, to be legally valid. Witnesses to this document must not be:

• The person designated as agent;
• A health care provider;
• An employee of a health care provider;
• The principal's heir or beneficiary.

Principal's Signature: ________________________ Date: ________________________

Witness 1 Signature: ________________________ Date: ________________________

Witness 2 Signature: ________________________ Date: ________________________

Notary Public (if applicable): ________________________ Date: ________________________

This document revokes any previous Medical Power of Attorney documents upon the dated signature of the principal. A copy of this document is as valid as the original.