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.)

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.

I have been provided with a disclosure statement explaining the effect of this document. I have read and understand that information contained in the disclosure statement.

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY.)

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:__________________________________________________

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. I have been provided with a disclosure statement explaining the effect of this document. I have read and understand that information contained in the disclosure statement. (YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY.) 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:__________________________________________________ Added by Acts 1991, 72nd Leg., ch. 16, Sec. 3.02(a), eff. Aug. 26, 1991. Renumbered from Civil Practice & Remedies Code Sec. 135.016 and amended by Acts 1999, 76th Leg., ch. 450, Sec. 1.05, eff. Sept. 1, 1999.