If you have already completed the Planning Guide and talked with your loved ones, the first form your need to complete is the Medical Power of Attorney form. This form allows you to select someone to carry out your wishes. These simple steps will help guide you as you complete the form. To download the form, click here.
Appoint Your Health Care Agent.
Name a person to act as an agent to carry out your health care choices if you are not capable of making them for yourself. This person may be a family member or friend that
- is at least 18 years old
- knows you wel
- can be there for you when you need them
- you trust to do what is best for you
- can tell the doctors about the decisions you have made for your care
Your Health Care Agent cannot be your doctor or someone who works at your hospital, clinic or residential facility unless he/she is a relative. The reason for this is because that person would have to choose between acting as your agent or your care provider.
Communicate limits you want your agent to follow:
You may write specifics of choices regarding care in the limitations section. For example, you can write down whether or not you want CPR, whether you would prefer to die at home or in a hospital, etc. You may find it simpler to list these choices in the Texas Directive to Physicians and Family or Surrogates form.
STEP 3 (Optional)
You may designate a first or second alternate agent if you choose.
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.
Sign and date the form.
Have two witnesses sign and date the form.
Please note that at least one of the two witnesses may not:
- be your health care agent
- be related to you by blood or marriage
- be entitled to get any part of your estate following your death
- be your attending physician or an employee of that physician
- be involved in providing direct patient care
- be an officer, director, partner or business office employee of the health care facility
OR if you do not have two witnesses, a notary public may sign on page 13
Make copies of this form and give them to your healthcare agent, your doctor, and other individuals involved in your care.
Discuss your choices with your health care agent, your doctor, and your loved ones.