Medical Power of Attorney Form - Texas

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 healthcare 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 healthcare decisions for me, I
designate the following persons to serve as my agent to make healthcare decisions for me as authorized
by this document, who serve in the following order:
A. First Alternate Agent
_____________________________________________________________
Name
_____________________________________________________________
Address Telephone
B. Second Alternate Agent
_____________________________________________________________
Name
_____________________________________________________________
Address Telephone
LOCATION OF DOCUMENT
The original document is kept at: _____________________________________________
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 healthcare 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
healthcare issues for myself.
(IF APPLICABLE) This power of attorney ends on the following date: ______________
PRIOR DESIGNATION REVOKED
I revoke any prior Medical Power of Attorney.
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Medical Power of Attorney Form - Texas PDF

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