Statutory Medical Power of Attorney, Texas

$25.00

This is a form of the Texas Medical Power of Attorney. It allows you to appoint an agent for health care decisions. If you wish to provide written instructions regarding for your health care and regarding life-sustaining or death delaying treatment should you become unable to make health care decisions for yourself, you will need to add the specific instructions to the form. Otherwise, the form assumes that you will have spoken with your agent about your instructions in advance. Specific instructions may also be included to limit the authority of the agent.

Format: Microsoft Word

TEXAS STATUTORY MEDICAL POWER OF ATTORNEY

(Texas Health & Safety Code,

Chapter 166, Sections 164.163 and 164.164)

MEDICAL POWER OF ATTORNEY DESIGNATION OF HEALTH CARE AGENT

I,_____________________________ (insert your name) appoint:

Name: ________________________________________________________

Address: ________________________________________________________

Phone: (home)_____________(cell) _____________ (work) ______________

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:

A. First Alternate Agent

Name: ________________________________________________________

Address: ________________________________________________________

Phone: (home)_____________(cell) _____________ (work) ______________

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Statutory Medical Power of Attorney, Texas is just $25.00 and can be immediately downloaded after purchase.