ADVANCE DIRECTIVE FOR HEALTH CARE

MEDICAL POWER OF ATTORNEY

DISCLOSURE STATEMENT

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 these decisions 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.

Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing your agent or your health or residential care provider orally or in writing or by your execution of a subsequent medical power of attorney. Unless you state otherwise, your appointment of a spouse dissolves on divorce.

This document may not be changed or modified. If you want to make changes in the document, you must make an entirely new one.

You may wish to designate an alternate agent in the event that your agent is unwilling, unable, or ineligible to act as your agent. Any alternate agent you designate has the same authority to make health care decisions for you.

THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES. THE FOLLOWING PERSONS MAY NOT ACT AS ONE OF THE WITNESSES:

1. the person you have designated as your agent;
   
2. a person related to you by blood or marriage;
   
3. a person entitled to any part of your estate after your death under a will or codicil executed by you or by operation of law;
   
4. your attending physician;
   
5. an employee of your attending physician;
   
6. an employee of a health care facility in which you are a patient if the employee is providing direct patient care to you or is an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility; or
   
7. a person who, at the time this power of attorney is executed, has a claim against any part of your estate after your death.
   

I have read this disclosure and I understand it.

Signature: ____________________________________

DESIGNATION OF HEALTH CARE AGENT

I, _________________________, appoint:

Name: _______________________
Address: _______________________
City: _______________________
State: The State of Texas
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 my physician certifies this fact in writing.

My agent is subject to no limitations other than those imposed by law or expressed herein.

In accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), I authorize my health care agent to review and receive any information regarding my physical or mental health, including medical and hospital records.

LOCATION OF DOCUMENTS:
The original of this document is kept at:

_________________________________________________________________________


The following individuals or institutions have signed copies:

Name: _____________________________

Address: __________________________________

Phone: _______________



Name: ____________________________

Address: __________________________________

Phone: _______________

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.

This power of Attorney ends on the following date: Not Applicable

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.

I sign my name to this medical power of attorney on ________ day of ________________, ________, at ______________ (city), _________ (State).

Signature: ________________
Name: _________________________

STATEMENT OF WITNESSES (Use only if document is not notarized.)
I am not the person appointed as agent by this document. I am not related to _________________________ by blood or marriage. I would not be entitled to any portion of _________________________'s estate on her 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 _________________________'s estate on her death. Furthermore, if I am an employee of a health care facility in which _________________________ is a patient, I am not involved in providing direct patient care to her 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: ____________________

Name: ________________________

Address: _____________________

Date: ___________________



Signature: ____________________

Name: ________________________

Address: _____________________

Date: ___________________

NOTARY ACKNOWLEDGMENT (Use only if document is not witnessed.)

STATE OF TEXAS

COUNTY OF  ___________________

The instrument was acknowledged before me on the ______ day of ______________, 20___, by_________________________.


______________________________________
Notary Public

My commission expires:  ___________________

RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________  Date: ____________________
2. ____________________________________  Date: ____________________
3. ____________________________________  Date: ____________________
4. ____________________________________  Date: ____________________
5. ____________________________________  Date: ____________________

DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES

EFFECT OF COPY
A copy of this Directive has the same effect as the original.

SEVERABILITY
If any part or parts of this Directive is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of such part or parts shall not in any way affect the remaining parts, and this document shall be construed as though the invalid or illegal part or parts had never been included herein. But if the intent of this Directive would be defeated by such construction, then it shall not be so construed.