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SECTION 3. Section 166.164,
Health and Safety Code, is amended to read as follows:
Sec. 166.164. FORM OF
MEDICAL POWER OF ATTORNEY. The medical power of attorney may
[must] be in [substantially]
the following form:
MEDICAL POWER OF ATTORNEY
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 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, annulled, or declared void unless this
document provides otherwise.)
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:
A. First Alternate Agent
Name:________________________________________________
Address:_____________________________________________
Phone
__________________________________________
B. Second Alternate Agent
Name:________________________________________________
Address:_____________________________________________
Phone
__________________________________________
The original of this document
is kept at:
_____________________________________________________
_____________________________________________________
_____________________________________________________
The following individuals or
institutions have signed copies:
Name:________________________________________________
Address:_____________________________________________
_____________________________________________________
Name:________________________________________________
Address:_____________________________________________
_____________________________________________________
DURATION.
I understand that this power
of attorney exists indefinitely from the date I execute this document
unless I establish a shorter time or revoke the power of attorney. If I am
unable to make health care decisions for myself when this power of attorney
expires, the authority I have granted my agent continues to exist until the
time I become able to make health care decisions for myself.
(IF APPLICABLE) This power
of attorney ends on the following date: __________
PRIOR DESIGNATIONS REVOKED.
I revoke any prior medical
power of attorney.
[ACKNOWLEDGMENT OF]
DISCLOSURE STATEMENT.
THIS MEDICAL POWER OF
ATTORNEY IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU
SHOULD KNOW THESE IMPORTANT FACTS:
Except to the extent you
state otherwise, this document gives the person you name as your agent the
authority to make any and all health care decisions for you in accordance
with your wishes, including your religious and moral beliefs, when you are
unable to make the decisions for yourself. Because "health care"
means any treatment, service, or procedure to maintain, diagnose, or treat
your physical or mental condition, your agent has the power to make a broad
range of health care decisions for you. Your agent may consent, refuse to
consent, or withdraw consent to medical treatment and may make decisions
about withdrawing or withholding life-sustaining treatment. Your agent may
not consent to voluntary inpatient mental health services, convulsive
treatment, psychosurgery, or abortion. A physician must comply with your
agent's instructions or allow you to be transferred to another physician.
Your agent's authority is
effective when your doctor certifies that you lack the competence to make
health care decisions.
Your agent is obligated to
follow your instructions when making decisions on your behalf. Unless you
state otherwise, your agent has the same authority to make decisions about
your health care as you would have if you were able to make health care
decisions for yourself.
It is important that you
discuss this document with your physician or other health care provider
before you sign the document to ensure that you understand the nature and
range of decisions that may be made on your behalf. If you do not have a
physician, you should talk with someone else who is knowledgeable about
these issues and can answer your questions. You do not need a lawyer's
assistance to complete this document, but if there is anything in this
document that you do not understand, you should ask a lawyer to explain it
to you.
The person you appoint as
agent should be someone you know and trust. The person must be 18 years of
age or older or a person under 18 years of age who has had the disabilities
of minority removed. If you appoint your health or residential care
provider (e.g., your physician or an employee of a home health agency, hospital,
nursing facility, or residential care facility, other than a relative),
that person has to choose between acting as your agent or as your health or
residential care provider; the law does not allow a person to serve as both
at the same time.
You should inform the
person you appoint that you want the person to be your health care agent.
You should discuss this document with your agent and your physician and
give each a signed copy. You should indicate on the document itself the
people and institutions that you intend to have signed copies. Your agent
is not liable for health care decisions made in good faith on your behalf.
Once you have signed this
document, you have the right to make health care decisions for yourself as
long as you are competent, and
treatment cannot be given to you or stopped over your objection. You have
the right to revoke the authority granted to your agent by informing your
agent or your health or residential care provider orally or in writing or
by your execution of a subsequent medical power of attorney. Unless you
state otherwise in this document, your appointment of a spouse is revoked
if your marriage is dissolved, annulled, or declared void.
This document may not be
changed or modified. If you want to make changes in this document, you
must execute a new medical power of attorney.
You may wish to designate
an alternate agent in the event that your agent is unwilling, unable, or
ineligible to act as your agent. Any
alternate agent you designate has
the same authority as the agent to make health care decisions for you.
THIS POWER OF ATTORNEY IS
NOT VALID UNLESS:
(1) YOU SIGN IT AND HAVE
YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC; OR
(2) YOU SIGN IT IN THE
PRESENCE OF TWO COMPETENT ADULT WITNESSES.
THE FOLLOWING PERSONS MAY
NOT ACT AS ONE OF THE WITNESSES:
(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.
By signing below, I
acknowledge that [I have been provided with a disclosure statement
explaining the effect of this document.] I have read and understand the
[that] information contained in the above disclosure
statement.
(YOU MUST DATE AND SIGN THIS
POWER OF ATTORNEY. YOU MAY SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED
BEFORE A NOTARY PUBLIC OR YOU MAY SIGN IT IN THE PRESENCE OF TWO COMPETENT
ADULT WITNESSES.)
SIGNATURE ACKNOWLEDGED BEFORE
NOTARY
I sign my name to this
medical power of attorney on __________ day of __________ (month, year) at
_____________________________________________
(City and State)
_____________________________________________
(Signature)
_____________________________________________
(Print Name)
State of Texas
County of ________
This instrument was
acknowledged before me on __________ (date) by ________________ (name of
person acknowledging).
_____________________________
NOTARY PUBLIC, State of Texas
Notary's printed name:
_____________________________
My commission expires:
_____________________________
OR
SIGNATURE IN PRESENCE OF TWO
COMPETENT ADULT WITNESSES
I sign my name to this
medical power of attorney on __________ day of __________ (month, year) at
_____________________________________________
(City and State)
_____________________________________________
(Signature)
_____________________________________________
(Print Name)
STATEMENT OF FIRST WITNESS.
I am not the person appointed
as agent by this document. I am not related to the principal by blood or
marriage. I would not be entitled to any portion of the principal's estate
on the principal's death. I am not the attending physician of the
principal or an employee of the attending physician. I have no claim
against any portion of the principal's estate on the principal's death.
Furthermore, if I am an employee of a health care facility in which the
principal is a patient, I am not involved in providing direct patient care
to the principal and am not an officer, director, partner, or business
office employee of the health care facility or of any parent organization
of the health care facility.
Signature:________________________________________________
Print
Name:___________________________________ Date:______
Address:__________________________________________________
SIGNATURE OF SECOND WITNESS.
Signature:________________________________________________
Print
Name:___________________________________ Date:______
Address:__________________________________________________
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SECTION 3. Section 166.164,
Health and Safety Code, is amended to read as follows:
Sec. 166.164. FORM OF
MEDICAL POWER OF ATTORNEY. The medical power of attorney must be in substantially the following form:
MEDICAL POWER OF ATTORNEY
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 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, annulled, or declared void unless this
document provides otherwise.)
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:
A. First Alternate Agent
Name:________________________________________________
Address:_____________________________________________
Phone __________________________________________
B. Second Alternate Agent
Name:________________________________________________
Address:_____________________________________________
Phone
__________________________________________
The original of this document
is kept at:
_____________________________________________________
_____________________________________________________
_____________________________________________________
The following individuals or
institutions have signed copies:
Name:________________________________________________
Address:_____________________________________________
_____________________________________________________
Name:________________________________________________
Address:_____________________________________________
_____________________________________________________
DURATION.
I understand that this power
of attorney exists indefinitely from the date I execute this document
unless I establish a shorter time or revoke the power of attorney. If I am
unable to make health care decisions for myself when this power of attorney
expires, the authority I have granted my agent continues to exist until the
time I become able to make health care decisions for myself.
(IF APPLICABLE) This power
of attorney ends on the following date: __________
PRIOR DESIGNATIONS REVOKED.
I revoke any prior medical
power of attorney.
[ACKNOWLEDGMENT OF]
DISCLOSURE STATEMENT.
THIS MEDICAL POWER OF
ATTORNEY IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU
SHOULD KNOW THESE IMPORTANT FACTS:
Except to the extent you
state otherwise, this document gives the person you name as your agent the
authority to make any and all health care decisions for you in accordance
with your wishes, including your religious and moral beliefs, when you are
unable to make the decisions for yourself. Because "health care"
means any treatment, service, or procedure to maintain, diagnose, or treat
your physical or mental condition, your agent has the power to make a broad
range of health care decisions for you. Your agent may consent, refuse to
consent, or withdraw consent to medical treatment and may make decisions
about withdrawing or withholding life-sustaining treatment. Your agent may
not consent to voluntary inpatient mental health services, convulsive
treatment, psychosurgery, or abortion. A physician must comply with your
agent's instructions or allow you to be transferred to another physician.
Your agent's authority is
effective when your doctor certifies that you lack the competence to make
health care decisions.
Your agent is obligated to
follow your instructions when making decisions on your behalf. Unless you
state otherwise, your agent has the same authority to make decisions about
your health care as you would have if you were able to make health care
decisions for yourself.
It is important that you
discuss this document with your physician or other health care provider
before you sign the document to ensure that you understand the nature and
range of decisions that may be made on your behalf. If you do not have a
physician, you should talk with someone else who is knowledgeable about
these issues and can answer your questions. You do not need a lawyer's
assistance to complete this document, but if there is anything in this
document that you do not understand, you should ask a lawyer to explain it
to you.
The person you appoint as
agent should be someone you know and trust. The person must be 18 years of
age or older or a person under 18 years of age who has had the disabilities
of minority removed. If you appoint your health or residential care
provider (e.g., your physician or an employee of a home health agency,
hospital, nursing facility, or residential care facility, other than a relative),
that person has to choose between acting as your agent or as your health or
residential care provider; the law does not allow a person to serve as both
at the same time.
You should inform the
person you appoint that you want the person to be your health care agent.
You should discuss this document with your agent and your physician and
give each a signed copy. You should indicate on the document itself the
people and institutions that you intend to have signed copies. Your agent
is not liable for health care decisions made in good faith on your behalf.
Once you have signed this
document, you have the right to make health care decisions for yourself as
long as you are able to make those
decisions, and treatment cannot be given to you or stopped over your
objection. You have the right to revoke the authority granted to your
agent by informing your agent or your health or residential care provider
orally or in writing or by your execution of a subsequent medical power of
attorney. Unless you state otherwise in this document, your appointment of
a spouse is revoked if your marriage is dissolved, annulled, or declared
void.
This document may not be
changed or modified. If you want to make changes in this document, you
must execute a new medical power of attorney.
You may wish to designate
an alternate agent in the event that your agent is unwilling, unable, or
ineligible to act as your agent. If you
designate an alternate agent, the
alternate agent has the same authority as the agent to make health care
decisions for you.
THIS POWER OF ATTORNEY IS
NOT VALID UNLESS:
(1) YOU SIGN IT AND HAVE
YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC; OR
(2) YOU SIGN IT IN THE
PRESENCE OF TWO COMPETENT ADULT WITNESSES.
THE FOLLOWING PERSONS MAY
NOT ACT AS ONE OF THE WITNESSES:
(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.
By signing below, I acknowledge
that [I have been provided with a disclosure statement explaining
the effect of this document.] I have read and understand the [that]
information contained in the above disclosure statement.
(YOU MUST DATE AND SIGN THIS
POWER OF ATTORNEY. YOU MAY SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED
BEFORE A NOTARY PUBLIC OR YOU MAY SIGN IT IN THE PRESENCE OF TWO COMPETENT
ADULT WITNESSES.)
SIGNATURE ACKNOWLEDGED BEFORE
NOTARY
I sign my name to this
medical power of attorney on __________ day of __________ (month, year) at
_____________________________________________
(City and State)
_____________________________________________
(Signature)
_____________________________________________
(Print Name)
State of Texas
County of ________
This instrument was acknowledged
before me on __________ (date) by ________________ (name of person
acknowledging).
_____________________________
NOTARY PUBLIC, State of Texas
Notary's printed name:
_____________________________
My commission expires:
_____________________________
OR
SIGNATURE IN PRESENCE OF TWO
COMPETENT ADULT WITNESSES
I sign my name to this
medical power of attorney on __________ day of __________ (month, year) at
_____________________________________________
(City and State)
_____________________________________________
(Signature)
_____________________________________________
(Print Name)
STATEMENT OF FIRST WITNESS.
I am not the person appointed
as agent by this document. I am not related to the principal by blood or
marriage. I would not be entitled to any portion of the principal's estate
on the principal's death. I am not the attending physician of the
principal or an employee of the attending physician. I have no claim
against any portion of the principal's estate on the principal's death.
Furthermore, if I am an employee of a health care facility in which the
principal is a patient, I am not involved in providing direct patient care
to the principal and am not an officer, director, partner, or business
office employee of the health care facility or of any parent organization
of the health care facility.
Signature:________________________________________________
Print
Name:___________________________________ Date:______
Address:__________________________________________________
SIGNATURE OF SECOND WITNESS.
Signature:________________________________________________
Print
Name:___________________________________ Date:______
Address:__________________________________________________
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