Slide 1: INFORMATION CONCERNING A MEDICAL POWER OF ATTORNEY THIS IS AN IMPORTANT LEGAL DOCUMENT. SHOULD KNOW THESE IMPORTANT FACTS: BEFORE
SIGNING THIS DOCUMENT, YOU
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 them 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, psycho-surgery, 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
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Slide 2: 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 (2) COMPETENT ADULT WITNESSES. THE FOLLOWING PERSONS MAY NOT ACT AS ONE OF THE WITNESSES: (1) (2) (3) (4) (5) (6) the person you have designated as your agent; a person related to you by blood or marriage; 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; your attending physician; an employee of your attending physician; 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 offce employee of the health care facility or of any parent organization of the health care facility; or a person who, at the time this power of attorney is executed, has a claim against any part of your estate after your death. ACKNOWLEDGMENT OF RECEIPT OF DISCLOSURE I RECEIVED AND READ THIS DISCLOSURE STATEMENT PRIOR TO SIGNING OF THE MEDICAL POWER OF ATTORNEY, AND I UNDERSTAND THE INFORMATION CONTAINED IN THIS DISCLOSURE STATEMENT. Date: _______________ __________________________________ Signature
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HEALTH CARE POWER & DIRECTIVE/LIVING WILL
Slide 3: MEDICAL POWER OF ATTORNEY & DIRECTIVE TO PHYSICIANS & AGENT (?LIVING WILL”) DESIGNATION OF HEALTH CARE AGENT & DIRECTIVE TO PHYSICIANS Section 166.151, Texas Health and Safety Code, as amended, is a Texas law authorizing medical powers of attorney and section 166.001 et seq of the Texas Health and Safety Code, as amended, is a Texas law authorizing directives to physicians. Both laws are contained in what is commonly referred to as the ?Advanced Directives Act.” Pursuant to those two laws and my common law right to do so, my name being _______________________________________, I 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 medical power of attorney and directive to physicians takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my attending physician. Oral notification by me revoking a portion of this power shall not revoke other portions. It is my intention that this power of attorney and directive be honored by my family and physicians as the expression of my legal right to make decisions on the subject of my health care and legal right to accept the consequences of my decision. (If I am a female and able to bear children I understand that if I have been diagnosed as pregnant and that diagnosis is known to my physician, this document has no effect during my pregnancy.) Pursuant to the Advanced Directives Act limitations on the decision making authority of my agent and treatment decisions are as follows: If at any time I should have a condition described in columns I, II, III, IV or V below, I direct that those procedures or treatments indicated in the column on the left be withheld or withdrawn as
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Slide 4: indicated by the word ?NO” appearing under the condition. The word ?YES” means I want the procedure indicated for the particular condition. I understand that section 166.032(d) of the Texas Health and Safety Code reads in part: “The attending physician shall make the directive a part of the declarant's medical record.” In
the event this
form does not address a health care issue needing a decision, my agent may make that decision on my behalf if I lack the capacity to make it.
II COMA OR PERSISTENT VEGETATIVE STATE WITH NO CHANCE OF REGAINING AWARENESS III COMA WITH SMALL CHANCE OF RECOVERY & GREATER CHANCE OF SURVIVING WITH BRAIN DAMAGE V IV IRREVERSIBLE BRAIN DAMAGE OR DISEASE IRREVERSIBLE BRAIN DAMAGE OR DISEASE, & TERMINAL ILLNESS
I COMA WITH CHANCE OF REGAINING AWARENESS
PROCEDURE OR TREATMENT CARDIOPULMONARY RESUSCITATION MECHANICAL BREATHING TRANSCUTANEOUS CARDIAC PACING DEFIBRILLATION ADVANCED AIRWAY MANAGMENT ARTIFICIAL NUTRITION ARTIFICIAL HYDRATION MAJOR SURGERY KIDNEY DIALYSIS CHEMOTHERAPY MINOR SURGERY INVASIVE DIAGNOSTIC TESTS BLOOD OR BLOOD PRODUCTS ANTIBIOTICS PAIN MEDICATIONS
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Slide 5: 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 (optional) Name: ______________________________________________ Address: ___________________________________________ _____________________________ Phone: ________________ B. Second Alternate Agent (optional) Name: ____________________________________________ Address: __________________________________________ ____________________________ Phone: _______________
The original of this document is kept at the following location: 9 residence, 9 office, 9 safe deposit box, 9 other ______________________________.
The following individuals or institutions have signed copies of this document (optional): Name: ________________________________________________ Address: _____________________________________________ Name: ________________________________________________ Address: _____________________________________________
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Slide 6: DURATION OR LENGTH OF EXISTENCE OF THIS MEDICAL POWER OF ATTORNEY I understand that this power of attorney exists indefinitely from the date I execute this document unless I establish a shorter time (in the blank following this paragraph) 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. (IF APPLICABLE) This power of attorney ends on the following date: PRIOR DESIGNATIONS REVOKED I revoke any prior medical power of attorney. HEALTH CARE INFORMATION .
Without limiting the generality of any other provision contained herein, my Agent is hereby empowered, without limitation: (1) to obtain medical records and other health information pertaining to me and to my medical and/or pharmaceutical history, to authorize any party in possession of such records and/or information to release such to my Agent and/or to transfer such to another party or parties as my Agent may direct; and (2) to pay for such services out of any property I may now or hereafter own or claim under such terms and conditions as may seem prudent to my Agent. I intend hereby to appoint my Agent to be my "personal representative" for the purposes of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), as implemented by Rules and Regulations issued by the Department of Health and Human Services, especially as provided in 45 CFR 640.502, as such Act and such Rules and Regulations may be amended from time to time. I am aware that I can authorize certain acts or omissions to be done or not done only by signing and delivering a Directive to Physicians and Family or Surrogates and/or by signing a delivering a Medical Power of Attorney, neither of which has any force or effect, however, until such time as I am unable to make decisions for myself; but the provisions of this Power of Attorney shall be read, construed and applied so as to be consistent with and not inconsistent with any such Directive or any such Power of Attorney and, in any event, as granting authority to my Agent to act for me and for my benefit to the extent that it is possible for me to delegate such to my Agent under a Power of Attorney of this sort.
CONFLICTS WITH OTHER DOCUMENTS To the extent that the directives or authorizations in this document conflict with directives or authorizations in another document signed by me, the instrument signed later in time controls. ACKNOWLEDGMENT OF DISCLOSURE STATEMENT
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Slide 7: 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 understand the full import of this power of attorney and directive and I am emotionally and mentally competent to make this directive.
I sign my name to this medical power of attorney and directive on this the ______ day of __________________, 20______, at __________________, ___________________ County, Texas. I UNDERSTAND THAT THE LAWS OF TEXAS DO NOT REQUIRE THIS DOCUMENT TO BE SIGNED AND WITNESSED BEFORE A NOTARY PUBLIC, BUT THAT OTHER STATES MAY REQUIRE IT. _______________________________________ Signature _______________________________________ Printed Name
STATEMENT OF WITNESSES
I am not the person appointed as agent by this document. I am not related to the principal by blood or marriage. I would not be entitled to any portion of the principal’s estate on the principal’s death. I am not the attending physician of the principal or an employee of the attending physician. I have not claim against any portion of the principal’s estate on the principal’s death. Furthermore, if I am an employee of a health care facility in which the principal is a patient, I am not involved in providing direct patient care to the principal and am not an officer, director, partner, or business
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Slide 8: office employee of the health care facility or of any parent organization of the health care facility.
____________________________ Witness Signature ____________________________ Printed Name ____________________________ Address ____________________________ ____________________________ Witness Signature ____________________________ Printed Name ____________________________ Address ____________________________
K
Lake Creek Office Park 13740 Research Boulevard, Suite H-3 Austin, Texas 78750-1837
(512)335-0208 [Notarization is optional in Texas, but may be required in other states.]
Subscribed and acknowledged before me by _______________________________________, and subscribed and sworn to before me by the said ___________________________________ and __________________________ as witnesses, this ___________ day of _____________ 20____.
__________________________________ Notary Public, State of Texas [S E A L]
29-052006.HEALTH 05 rev050206
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