Texas Medical Power of Attorney and Disclosure Statement Form
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Medical Power of Attorney And Disclosure Statement Page 1
THE MEDICAL POWER OF ATTORNEY
THIS 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 no longer capable of
making them 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 begins 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 had.
It is important that you discuss this document with your physician or other health care
provider before you sign it to make sure 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 home, or residential care home, 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 permit a person to do 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 who have
signed copies. Your agent is not liable for health care decisions made in good faith on your
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