Texas Medical Power of Attorney Form

The Texas Medical Power of Attorney Form is a legal document that will permit a Principal to designate an Attorney In Fact/Agent to oversee the management of the Principal’s health care, in the event of incapacitation, disability, or otherwise becomes unable to make their own health care decisions. Once the document is completed, witnessed and acknowledged, the document shall become effective upon express written statement by a physician stating the Principal is no longer able to make their own health care decisions. Once the Agent acquires powers, the Principal’s physician must adhere to the decisions and instructions of the Agent.

It’s recommended that the Principal consult with knowledgeable legal counsel for a clear view of what the Principal should expect by completion of this document. This document shall provide no powers to the Agent with regard to any financial powers. All signatories must be present before a notary public or before two (2) witnesses who will provide signatures in acknowledgement .

This document may, at the Principal’s discretion, be revoked by placing the revocation into writing and having it served or delivered to the Agent(s). The revocation shall not be legally acceptable until it’s known to be in the possession of the Agent.

How to Write

Step 1 – The Parties – Enter the following:

  • Principal’s name
  • AND
  • Name of delegated Agent
  • Complete address with zip code
  • Telephone number

Step 2 – Limitations of Authority –

  • Principal must enter any limitations or restrictions regarding health care decisions

Step 3 – Alternate Agent(s) – Optional:

  • Enter the Agent(s) names
  • Addresses
  • Phone numbers

Step 4 – Location of Original Document –

  • Enter a name and address as to where the document(s) is/are kept
  • Submit the names and addresses of individuals or institutions with signed copies of the document

Step 5 – Duration –

  • The Principal must review and agree to the statement pertaining to the duration of the powers document
  • Should the Principal choose to provide a termination date, enter it into the box provided, in mm/dd/yyyy format

Step 6 – Acknowledgement of Disclosure Statement – The Principal must read the statement and sign before a notary providing the following:

  • Enter the date of the signature in dd/m/yyyy format
  • City
  • State
  • Principal’s signature
  • Printed name
  • The notary shall complete this section with state required information
  • OR
  • Two witnesses must read and agree to the statement and provide
  • Signatures
  • Printed names
  • Dates of signatures
  • Addresses