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Texas Medical Power of Attorney Form

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Texas Medical Power of Attorney Form allows a state resident to designate a loved one to take care of his or her health care decisions in the event he or she can no longer communicate his or her wishes. Before your agent can make decisions, your doctor will have to certify that you are incapable of doing so yourself. It is important to choose someone who will have your best interests at heart and who knows your desires for medical treatment.

Definition – Sec. 166.002(11)

Laws – Title 2, Chapter 166 (Advance Directives)

Living Will – Declaration that guides doctors to a person’s preferred treatment options during their and last life stages.

Durable (Financial) Power of Attorney – With this document complete, the agent of your choosing will be able to make financial decisions and transactions on your behalf.

How to Write

1 – Select The Template File Version To Download

There are three buttons on this page, located in the same area of the template picture, that will each provide access to the paperwork required to appoint a Texas Health Care Representative. Download a copy to your computer in the format you intend to work with.

2 – The Principal Must Acknowledge Disclosure Comprehension

The first couple of pages in this paperwork will present some information the Principal must read. If the Principal does not understand any part of the information in these pages, he or she must consult with an appropriate entity (i.e. medical attorney, physician, etc.). When the Principal has read and comprehended these pages in full, he or she should supply a Signature and Signature Date just below the bold statement beginning with “I Have Read And Understand…”

3 – The Statement Of The Principal’s Intent Will Request Information

The first sentence below the Title will serve as documentation of the Principal’s desire to appoint an Agent with the Authority required to make Medical Decisions regarding the Principal’s Health Care on behalf of the Principal. In order for this sentence to apply to the situation at hand, it will have to be furnished with specific information. We will begin by identifying the individual at the heart of this document: the Principal. Enter the full Name of the person who is giving someone the right to make Health Care decisions on his or her behalf (if incapacitated).The next three blank spaces (labeled “Name,” “Address,” and “Phone”) refer to the Health Care Agent being appointed with Principal Power. Record the Full Name, the Residential Address, and Current Telephone Number of the individual who will make Health Care Decisions for the Principal when the Principal is incapacitated and/or unable to communicate in their respectively labeled areas.

4 – Principal Limitations Should Be Set In This Document So They May Be Applied

The Principal should be aware of the scope of Power being delivered to a Health Care Agent regarding Medical Decisions as they were discussed at the beginning of this paperwork. He or she can impose limitations in any Decisions or Actions that can be made by the Health Care Agent. Several blank lines under the bold words “Limitations On The Decision-Making Authority Of My Agent…” have been supplied if the Principal wishes to apply such limitations or even restrictions upon the Principal Authority delivered to the Agent.

5 – Document Any Alternate Agents Should Be Held In Reserve

The Principal can appoint Alternate Agents that will automatically be appointed with the same Principal Powers given to the Health Care Agent if or when the Health Care Agent is unwilling, unable, or ineligible to wield Principal Power. Two areas (“A. First Alternate Agent” and “B. Second Alternate Agent”) have been supplied so the Principal can declare the identity of each of these Agents. It should be noted that both Agents will not be appointed with Principal Power at the same time but in a successive manner with the First Alternate Agent being appointed Authority before the Second Alternate Agent can. The Second Agent will only be granted Power if both the Health Care Agent and the First Alternate Agent are no longer wielding Principal Power. Use the blank spaces in each of these areas (labeled “Name,” “Address” and “Phone”) to declare the identity and contact information of the First Alternate Agent and Second Alternate Agent.

6 – Provide Some Specifics Regarding The Original Copy Of This Document

The next task will be to disclose where an original copy of this document will be stored. Record the Physical Address of this location on the blank space after the words “The Original OF This Document Is Kept At” It will also be necessary to furnish the Full Name and Physical Address of an entity who will hold a signed copy of this document and can be reliably reached at any time. Produce this information using the “Name” and “Address” line below the sentence “The Following Individual Or Institution Has A Signed Copy Of This Directive”

7 – Address The Life Span Of This Paperwork

By default, this document’s appointment of Principal Powers to the Health Care Agent will remain in effect indefinitely. However, if the Principal wishes to set a Date where it shall terminate automatically then enter the Date of Termination on the blank line provided in the section titled “Duration.”

8 – The Principal Must Date And Sign This Appointment Before Two Witnesses

This paperwork will not be a viable tool of delegation for these Principal Powers unless the Principal supplies a Dated and Witnessed Signature. He or she should begin this process by entering the Current Date the Principal Act of Signing will be performed using the first three blank spaces in the sentence “I Sign My Name To This Durable Power…” After recording the Date when this signing occurs, the Principal should use the last blank area in this sentence to document the City and State where he or she is signing this paperwork.Once the Principal has supplied the above information, he or she should Print then Sign his or her Name on the blank spaces labeled “Print Name” and “Signature.”As soon as the Principal has signed this paperwork, it should be given to the two Witnesses who have watched the signing occur. Each Witness will have his or her own area with the blank lines “Witness Signature,” “Print Name,” “Date,” and “Address.” Each Witness must tend to one area by supplying his or her Signature, Printed Name, Date, and Address where appropriate.


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