Disclosure Statement Form For Medical Power Of Attorney printable pdf download

Disclosure Statement for Medical Power of Attorney

Advance Directives Act (see §166.163, Health and Safety Code)

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 behalf.

Disclosure Statement Form For Medical Power Of Attorney