Durable Power of Attorney for Health Care - Texas

DURABLE POWER OF AITORNEY FOR HEALTH CARE
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 durable power of attorney for health care 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: ___________________________________________________________________
Nrsg EOL Form #2 Revised: December 26, 2002 Page 3 of 5
Page 3/5
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Durable Power of Attorney for Health Care - Texas PDF

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