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 when 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 or agents, 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:

First Alternate Agent

Name:___________________________________________________

Address:_________________________________________________

Phone:__________________________________________________

Second Alternate Agent

Name:___________________________________________________

Address:_________________________________________________

Phone:__________________________________________________

The original of this document is kept at:

_________________________________________________________

The following individuals or institutions have signed copies in their possession:

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 the information contained in the

Disclosure Statement.

(You must date and sign this Medical Power of Attorney to make it effective.

You have two options. The first option is to sign and have it acknowledged

before a notary public. The second is to sign before two witnesses who also

sign. The first witness must meet the requirements described later.)

(First Option Before a Notary)

I sign my name to this Medical Power of Attorney on _____________ day of

____________________ (month, year) at

____________________________________________________________

(City and State)

____________________________________________________________

(Signature)

____________________________________________________________

(Print Name)

State of Texas

County of _______________

This instrument was acknowledged before me on ________________ (date)

by _______________________________ (name of person acknowledging).

________________________________________

NOTARY PUBLIC, State of Texas

Notary's printed name:

________________________________________

My commission expires:

________________________________________

– – – – – – – – – – – – – – – – – – – OR – – – – – – – – – – – – – – – – – – – –

(Second Option Before Two Competent Witnesses)

I sign my name to this Medical Power of Attorney on __________ day of

____________________ (month, year) at

____________________________________________________________

(City and State)

____________________________________________________________

(Signature)

____________________________________________________________

(Print Name)

Statement and Qualifications 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: ___________________________________________________