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Texas Medical Power of Attorney Form
Medical Power Of Attorney
Advance Directives Act (see ยง166.164, Health and Safety Code)
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 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: :
(continued on reverse)
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Texas Medical Power of Attorney Form