Texas Medical Power of Attorney Form

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Updated June 02, 2022

A Texas medical power of attorney allows a person to select someone else to make health decisions on their behalf. The principal can limit or give unrestricted powers to the agent to make any type of responsibility, including ending the principal’s life. Alternate agents may also be selected in the event the primary agent cannot perform.

Definition

(11) “Medical power of attorney” means a document delegating to an agent authority to make health care decisions executed or issued under Subchapter D.

Laws

  •  Signing Requirements – Two (2) witnesses or a notary public (Sec. 166.154). None of the following may act as a witness:
    1. The person you have designated as your agent;
    2. A person related to you by blood or marriage;
    3. A person entitled to any part of your estate after your death under a will or codicil executed by you or by operation of law;
    4. Your attending physician;
    5. An employee of your attending physician;
    6. An employee of a health care facility in which you are a patient if the employee is providing direct patient care to you or is an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility; or
    7. A person who, at the time this medical power of attorney is executed, has a claim against any part of your estate after your death.
  • Statutes§ 166.151 (Medical Power of Attorney)

How to Write

Download: Adobe PDF

I. Texas Appointment Of Authority

(1) Texas Principal. Identify the Principal who will entitle another Party to decide upon his or her medical treatment when unable to communicate with Physicians and diagnosed (in writing) as being unable to accurately represent himself or herself. The identity of the Principal issuing this document to grant this kind of authority will have to be established in the first statement by recording his or her entire name as requested.

(2) Texas Health Care Agent For Principal. The Health Care Agent is the Party the Principal wishes Texas Medical Staff to turn to when he or she is in need of medical treatment that requires decisions from the Principal while he or she is unable to communicate. For the Principal to formally appoint such an Agent, the submission of the Texas Health Care Agent’s complete legal name must be made to the appointment statement.

(3) Contact Information Of Texas Health Care Agent. The home address where the Texas Health Care Agent can be found and the telephone number where he or she can be reached should be presented using the next two areas. This information must be up-to-date since any Texas Medical Staff treating the Principal is likely to use this document to contact his or her Health Care Agent.

II. Limitations On Agent’s Principal Powers

(4) Restrictions Or Conditions On Texas Health Care Agent. The Principal can impose limitations on the decision-making powers that will be appointed to the Texas Health Care Agent using this paperwork as well. This is important since the Texas Health Care Agent’s principal powers become effective only when the Principal has been declared as unable to effectively communicate. Thus, since extremely difficult decisions may need to be made, the Principal should use the area in the second article to discuss treatments and scenarios where he or she does not wish Medical Staff to follow the Health Care Agent’s directions but rather his or her own as they are presented in this area. Any conditions or restrictions the Texas Principal wishes imposed on when or how the Health Care Agent may decide on medical treatments (for the Principal) should also be dispensed in this section. The Principal should endeavor to be as inclusive as possible when discussing his or her preferences regarding medical treatment and decisions over his or her health care as he or she wishes them applied to the Health Care Agent’s decision-making authority or as direct instructions to attending Texas Medical Staff.

III. Alternate Texas Medical Agents

(5) First Alternate Agent Name. If the Texas Health Care Agent being appointed above cannot act for the Principal, will not act for the Principal, or is unreachable when Medical Staff require treatment decisions then the Principal can be left vulnerable to delays in needed health care decisions. If desired, an additional Party can be approved to represent the Principal if or when the Texas Health Care Agent cannot act. This Alternate Agent will only be able to use the principal authority this document grants if the original Texas Health Care Agent must be replaced while the Principal is incapacitated. Produce the name of the First Alternate Agent so that he or she can be formally named as having the right to assume the Texas Health Care Agent role should it become vacant while the Principal is incapacitated.

(6) Address Of First Alternate Agent. Due to the nature of this appointment, it is imperative that Reviewers are able to contact or reach the First Alternate Agent quickly. To aid this, supply the full home address of the First Alternate Agent.

(7) Phone Number Of First Alternate Agent. Complete this report on the First Alternate Agent’s contact information with a record of his or her contact telephone number.

(8) Second Alternate Texas Health Care Agent. An area has also been reserved so that a Second Alternate Agent can be set through this document. The Second Texas Alternate Health Care Agent will only have the ability (and authority) to act as the Principal’s Primary Health Care Agent if the role becomes vacant and neither of the previously named Parties can or will fill it. This Second Alternate Agent can only act in this capacity if he or she is granted the approval of the Principal to do so. To this effect, produce the name, address, and the telephone number of the Party the Principal wishes appointed as the Second Alternate Texas Health Care Agent to the areas reserved for this information.

IV. Dispensed Copies Of Texas Appointment

(9) Storage Of Original Texas Instrument. This paperwork will serve as an instrument of communication between the Principal and his or her Health Care Providers and Agents (in the State of Texas) in addition to providing authorization that the Health Care Agent requires to make treatment decisions on the Principal’s behalf when appropriate. The physical location of the executed original document must therefore be established before it is signed. Furnish the address and location where the original will be kept as well as the name of any Contact Person needed to obtain it.

(10) Copy Location(s) Of Texas Instrument. It is recommended that the Medical Providers who will likely be responsible for the Principal’s care and his or her relatives be given a copy of this document for reference. Every Party and location holding a copy of this executed directive should be presented in the section provided.

V. Duration Of Texas Appointment

(11) Optional Date Of Termination. By default, the medical decision-making powers that the Health Care Agent can assume in the State of Texas will remain in effect until the Principal revokes them. However, since the Principal retains medical decision-making powers at all times while able, he or she has the option to set a termination date to this document. If desired, document the exact date when the principal powers will automatically revoke regardless of the health status of the Principal to set this termination date.

VI. Signing Process Required Of Texas Principal Of Medical Authority

(12) Texas Principal Signature Date. When the Principal is ready to execute his or her signature, two Witnesses or a Notary Public will need to be present. The calendar date when all Parties gather so that the Principal may execute this statement should be presented across the spaces displayed calendar date declaration made.

(13) Location Of Signing. The city and the state where the signing occurs must be presented.

(14) Signature Of Texas Principal. The two Witnesses or Notary present must watch the Principal sign his or her name.

(15) Verification By Notary Public. If the Principal has elected to participate in the notarization process then the Notary Public shall complete the area provided in the next section. He or she will establish the facts behind the signing (i.e. the Parties, date, and location) and prove the process as complete.

(16) First Witness Testimonial. If the Principal has decided to use Witnesses to verify his or her act of signing, then the First Witness must review the “Statement Of First Witness” section. This will place a strict criteria on who the first Witness may be. For instance, the First Witness may not be blood relative, adopted relative or Spouse of the Principal. Once the First Witness has reviewed the “Statement Of First Witness” and can verify that it is accurate, he or she must produce his or her signature.

(17) Signature Date Of First Witness. After signing the testimonial, the First Witness must document the date.

(18) Printed Name And Address. The name and address of the First Witness must be submitted to this testimonial to support the signature made.

(19) Second Witness Signing. The signature of the Second Witness will be required to verify that he or she has watched the Principal sign this document and that he or she is an impartial adult who satisfies the legal criteria to testify the signature produced by the Principal is authentic.

(20)Date Of Second Witness Signature. The Second Witness should produce the calendar date when he or she signed this document. Note that all signature dates produced by these Parties should be the same.

(21) Date Of Second Witness Signature. Name And Address. The Second Witness should supply his or her printed name and address after submitting the signature required to acknowledge the testimonial made.