Health & Safety Code Section 166.164
Form of Medical Power of Attorney
(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, annulled, or declared void unless this document provides otherwise.)
(IF APPLICABLE)This power of attorney ends on the following date: __________
(1)YOU SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC; OR
(2)YOU SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT 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 medical power of attorney is executed, has a claim against any part of your estate after your death.
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY. YOU MAY SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC OR YOU MAY SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES.)
Section 166.164 — Form of Medical Power of Attorney,
https://statutes.capitol.texas.gov/Docs/HS/htm/HS.166.htm#166.164 (accessed Dec. 9, 2023).