Texas Medical Power of Attorney Template
This Texas Medical Power of Attorney allows you to designate someone to make medical decisions on your behalf if you become unable to do so. This document is governed by the Texas Health and Safety Code, Chapter 166.
Principal Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: _____________________
- Date of Birth: ________________________
Agent Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: _____________________
- Phone Number: ________________________
Alternate Agent Information (if applicable):
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: _____________________
- Phone Number: ________________________
Effective Date: This Power of Attorney becomes effective when I am unable to make my own medical decisions.
Durability: This Power of Attorney shall remain in effect until revoked by me in writing or until my death.
Medical Decisions: My agent shall have the authority to make decisions about my medical treatment, including but not limited to:
- Choosing healthcare providers.
- Consent to or refuse treatment.
- Accessing my medical records.
- Making end-of-life decisions.
Signatures:
By signing below, I affirm that I am of sound mind and understand the contents of this document.
_______________________________
Signature of Principal
Date: ______________________
_______________________________
Signature of Agent
Date: ______________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to the Principal or the Agent.
_______________________________
Signature of Witness 1
Date: ______________________
_______________________________
Signature of Witness 2
Date: ______________________