Texas Medical Power of Attorney
This Texas Medical Power of Attorney is a legal document that allows an individual (the “Principal”) to designate another person (the “Agent”) to make health care decisions on their behalf if they become unable to make these decisions for themselves. This document is governed by the laws of the State of Texas, including but not limited to the Texas Health and Safety Code Chapter 166.164.
Principal Information
Full Name: ___________________________________
Date of Birth: _______________________________
Address: _____________________________________
Agent Information
Full Name: ___________________________________
Address: _____________________________________
Primary Phone: _______________________________
Alternative Phone: ___________________________
Alternate Agent Information (Optional)
If the primary Agent is not willing, able, or reasonably available to make health care decisions, an alternate Agent can act in their place. This section is optional and can be left blank if the Principal does not wish to designate an alternate Agent.
Full Name: ___________________________________
Address: _____________________________________
Primary Phone: _______________________________
Alternative Phone: ___________________________
Scope of Authority
The Agent is authorized to make health care decisions on the Principal's behalf, including but not limited to:
- Consent to or refusal of medical care.
- Selection or discharge of health care providers and institutions.
- Access to medical records.
Special Instructions
The Principal may state any specific limitations on the Agent's authority or provide other special instructions here:
______________________________________________________________________________
______________________________________________________________________________
Effective Date and Duration
This Medical Power of Attorney becomes effective upon the incapacity of the Principal to make health care decisions and remains in effect unless revoked by the Principal or until the Principal's death.
Signatures
This document must be signed by the Principal in the presence of two qualified witnesses or a notary public, as required by Texas law.
Principal’s Signature: __________________________ Date: _________________
Witness 1 Signature: __________________________ Date: _________________
Witness 2 Signature: __________________________ Date: _________________
or
Notary Public Signature: _______________________ Date: _________________
Seal: