Texas Medical Power of Attorney Form: Free Template (2026)

Medical Power of Attorney (Texas)

MEDICAL POWER OF ATTORNEY DESIGNATION OF HEALTH CARE AGENT.

I, [Your Full Legal Name] appoint:

Name: [Agent’s Full Name]
Address: [Agent’s Street Address, City, State, ZIP]
Phone: [Agent’s 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 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:

[Write any limits on your agent’s authority, or write “None”]

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, annulled, or declared void unless this document provides otherwise.)

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: [First Alternate Agent’s Full Name]
Address: [Street Address, City, State, ZIP]
Phone: [Phone]

B. Second Alternate Agent

Name: [Second Alternate Agent’s Full Name]
Address: [Street Address, City, State, ZIP]
Phone: [Phone]

The original of this document is kept at:

[Where the signed original is kept, for example: home address, safe location]

The following individuals or institutions have signed copies:

Name: [Name]
Address: [Address]

Name: [Name]
Address: [Address]

[Add lines as needed]

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 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: [Date, or leave blank]

PRIOR DESIGNATIONS REVOKED.

I revoke any prior medical power of attorney.

DISCLOSURE STATEMENT.

THIS MEDICAL POWER OF ATTORNEY IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:

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 unable to make the decisions for 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, psychosurgery, or abortion. A physician must comply with your agent’s instructions or allow you to be transferred to another physician.

Your agent’s authority is effective 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 if you were able to make health care decisions for yourself.

It is important that you discuss this document with your physician or other health care provider before you sign the document to ensure 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 facility, or residential care facility, 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 allow a person to serve as 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 institutions that you intend to have signed copies. Your agent is not liable for health care decisions made in good faith on your behalf.

Once you have signed this document, you have the right to make health care decisions for yourself as long as you are able to make those decisions, 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 in this document, your appointment of a spouse is revoked if your marriage is dissolved, annulled, or declared void.

This document may not be changed or modified. If you want to make changes in this document, you must execute a new medical power of attorney.

You may wish to designate an alternate agent in the event that your agent is unwilling, unable, or ineligible to act as your agent. If you designate an alternate agent, the alternate agent has the same authority as the agent to make health care decisions for you.

THIS POWER OF ATTORNEY IS NOT VALID UNLESS:

(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.

THE FOLLOWING PERSONS MAY NOT ACT AS ONE OF THE 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.

By signing below, I acknowledge that I have read and understand the information contained in the above disclosure statement.

(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.)

SIGNATURE ACKNOWLEDGED BEFORE NOTARY

I sign my name to this medical power of attorney on [Day] day of [Month, Year] at [City and State]

___________________________
(Signature)

[Your Printed Name]
(Print Name)

State of Texas
County of [County]

This instrument was acknowledged before me on [Date] by [Name of Person Acknowledging].

___________________________
NOTARY PUBLIC, State of Texas
Notary’s printed name: [Notary’s Printed Name]
My commission expires: [Date]

OR

SIGNATURE IN PRESENCE OF TWO COMPETENT ADULT WITNESSES

I sign my name to this medical power of attorney on [Day] day of [Month, Year] at [City and State]

___________________________
(Signature)

[Your Printed Name]
(Print Name)

STATEMENT OF FIRST WITNESS.

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 no 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 office employee of the health care facility or of any parent organization of the health care facility.

Signature: ___________________________
Print Name: [First Witness’s Printed Name]
Date: [Date]
Address: [First Witness’s Address]

SIGNATURE OF SECOND WITNESS.

Signature: ___________________________
Print Name: [Second Witness’s Printed Name]
Date: [Date]
Address: [Second Witness’s Address]

Before You Fill It In (Delete This Section)

• Keep the statutory text. A Texas medical power of attorney “must be in substantially the following form” (Health and Safety Code § 166.164). The form above follows that text in order; fill in the bracketed blanks and do not add or rewrite clauses inside it. The free Texas HHS version (“Medical Power of Attorney Designation of Health Care Agent (MPOA)”, revision 05-2024) carries the same text.

• Limitations. Write “None” or list your limits in the limitations section, for example: a treatment you do not want your agent to consent to; a statement that your spouse’s appointment as agent continues if your marriage is dissolved, annulled or declared void (otherwise it is revoked automatically, § 166.155(a-1)); or a note that you have also signed a Directive to Physicians and Family or Surrogates.

• Who can be your agent. Someone 18 or older, or a minor whose disabilities of minority have been removed by a court (§ 166.151). Your own doctor, or another health or residential care provider treating you, cannot act as your agent while serving as your provider, even if related to you. An employee of your provider (for example, hospital or nursing-home staff) cannot act as your agent while working as that provider’s employee, unless related to you (§ 166.153).

• Sign one way: notary or two witnesses. You do not need both (§ 166.154(a)–(b)). If you use witnesses, both must be competent adults, and the first witness must meet all seven tests in the disclosure statement and sign the Statement of First Witness (§§ 166.003(2), 166.154(a), 166.164). Do not use your agent or an alternate agent as the first witness. It is safer, though not required, to use two witnesses who both pass all seven tests.

• If you are physically unable to sign. Another person may sign your name in your presence and at your express direction (§ 166.154(c)).

• Electronic signatures. You, the witnesses and the notary may sign with a digital or electronic signature only if it can be verified, is under the signer’s sole control, is linked to the document so that any change to the data invalidates it, and stays with the document rather than in a separate file (§ 166.011). A digital signature must also use a department-approved algorithm, be unique to the signer and be bound to a digital certificate.

• When your agent can act. Only after your attending physician certifies in writing, and files in your medical record, that you are incompetent (§ 166.152(b)). Even then, treatment cannot be given or withheld over your objection (§ 166.152(c)).

• What your agent cannot do. Consent to voluntary inpatient mental health services, convulsive treatment, psychosurgery, abortion, or neglect of you through the omission of care primarily intended for your comfort (§ 166.152(f)). This form does not cover money; that takes a separate durable financial power of attorney (Estates Code §§ 751.0015(2), 752.051).

• Changing it. The signed form cannot be edited. To change anything, sign a new medical power of attorney and tell your old agent and your providers. You can also revoke it by telling your agent or a licensed or certified health or residential care provider, orally or in writing, or by any other act that shows you intend to revoke it, whatever your mental state (§ 166.155(a)).

• This is not legal advice. Talk to your doctor about the decisions your agent may face, and to a Texas attorney if anything is unclear.

After You Sign: Checklist (Delete This Section)

• Give the signed document to your agent. It takes effect on signing and delivery to the agent (§ 166.152(g)).

• Give signed copies to your alternate agents and your doctor, and list every person or institution that has one on the form.

• Ask your doctor to put a copy in your medical record.

• Keep the original where your agent can reach it. Texas has no filing or recording requirement for this document.

• Also consider a Directive to Physicians and Family or Surrogates for your end-of-life choices and, for mental health care, a Declaration for Mental Health Treatment (Civ. Prac. & Rem. Code ch. 137).

• If you want an out-of-hospital do-not-resuscitate order, ask your attending physician; it is a separate standard state form that the physician must sign (§§ 166.082, 166.083).