Free Texas Medical Power of Attorney Form

What Is a Texas Medical Power of Attorney?

A medical power of attorney is a document in which you, the principal, name an agent to make health care decisions for you if you cannot make them yourself. The agent is the person you name, and you may also hear this person called a health care proxy. Under section 166.152 of the Texas Health and Safety Code, your agent may make any health care decision on your behalf that you could make if you were competent, subject to any express limitation in the medical power of attorney. Your agent may act only if your attending physician certifies in writing, and files the certification in your medical record, that you are incompetent.^[1.4]

Texas has its own signing and agent rules, which the next section explains.

The FormsPal template pairs the appointment with an advance directive, a statement of your end-of-life wishes.

Use the sections below to check the Texas rules and then complete each part of the form.

Texas Medical Power of Attorney Requirements

Texas sets rules for how a medical power of attorney is signed and for who may serve as your agent. Both come from sections 166.153 and 166.154 of the Texas Health and Safety Code. The sections below put each rule in plain words, so you can check them before you sign.

Signing and Witness Rules

The principal is the person making the document. The medical power of attorney must be signed by the principal in the presence of two witnesses who qualify under section 166.003.^[1.2] If you are physically unable to sign, another person may sign the medical power of attorney with your name, in your presence and at your express direction. That person may use a digital or electronic signature authorized under section 166.011.^[1.3]

• At least two witnesses are required.
• The witnesses must sign the medical power of attorney.
• Who may serve as a witness is restricted by section 166.003. At least one of your witnesses must be a person who is not someone you designate to make a health care or treatment decision for you, and who is not related to you by blood or marriage.^[2.1]

Agent Restrictions

State law restricts who may serve as agent. A person may not exercise the authority of an agent while the person serves as:^[1.1]

• your health care provider
• an employee of your health care provider, unless the person is your relative
• your residential care provider
• an employee of your residential care provider, unless the person is your relative

Pick someone you trust and talk with them before you name them. That is common practice, not a legal requirement.

Texas Medical Power of Attorney Form Details

What Does the Texas Medical Power of Attorney Form Cover?

The FormsPal template is titled Medical Power of Attorney with Advance Directive. It has three numbered parts and a notary page, and what each part says comes from the printed text of the form, not from Texas law. Read all of it before you sign.

• Part I, Power of Attorney for Health Care. You name your agent here, with the agent’s phone and email. The form says the agent acts when you cannot make health care decisions yourself, and it includes a release that lets your agent see your medical records.
• Part II, Advance Health Care Directive. This part states your end-of-life wishes. The printed wording asks your providers to withhold or withdraw all treatments other than those needed to keep you comfortable.
• Part III, General Provisions. These are standard terms for the whole document. The signature and date lines come right after them.
• Acknowledgment. The last page is a block that a notary public completes.

Part II is a serious statement about end-of-life care, so check that it matches what you want. If it does not, talk to a lawyer or your doctor before you sign.

Questions to Settle Before You Sign

A medical power of attorney works best when the people involved know what you want. These questions are common practice, not legal requirements. Talk them through with your agent and your doctor before you fill in the form.

• Does the person you have in mind agree to serve as your agent?
• Does your agent know your wishes about treatment, including the end-of-life wishes in Part II?
• Who will hold the original, and who will get copies?
• Do you want to name the same person for money and property decisions? That is a separate document, covered on our Texas durable power of attorney page.

This page covers health care decisions only. For other kinds of authority, browse our Texas general power of attorney page.

Filling Out the Texas Medical Power of Attorney Form

The form has 21 fillable fields, and the four steps below follow it from page 1 to the last page. To start right away, use our fillable power of attorney form, or print the PDF and write your answers by hand. Each step names the part of the form it covers.

The screenshots under each step show the FormsPal Texas medical power of attorney template filled with sample entries in blue, so you can see where each answer goes. The names, addresses, dates and amounts are examples only.

1. Power of Attorney for Health Care: principal and agent. On page 1, enter your full name and home address as the principal. Next, enter the full name and address of the person you appoint as your agent. Add the agent’s phone number and email below. There is no start date to choose here, because paragraph 2 of the form fixes when the agent’s authority takes effect.

   

2. Signature and date. Read Parts I to III first. Then sign on the signature line at the end of Part III and write the date on the line below it. The next section explains who must be present when you sign.

   

3. Acknowledgment. Page 4 holds the acknowledgment. The notary public completes it, with the state, the county, the date, the notary’s name, your name as the person appearing, and the state in the perjury line.

   

4. Notary signature and seal. The notary signs on the Signature line at the bottom of page 4 and adds the official seal.

   

Signing and Using Your Medical Power of Attorney

Filling in the blanks is only part of the job. The steps below cover what happens around the form, from reading it to handing out copies. Follow the signing rules from the first section of this page.

1. Read the whole form. Go through Parts I to III and the acknowledgment. Check that Part II matches your wishes.
2. Check your agent. Confirm that your agent does not hold one of the barred roles listed under agent restrictions.^[1.1]
3. Choose how to sign. Either gather two witnesses who qualify under section 166.003, or plan to sign the document before a notary public instead.^[1.2]
4. Sign. The principal must sign in the presence of the two witnesses, and the witnesses must sign the medical power of attorney. With a notary, you sign and the notary completes the acknowledgment on page 4.^[1.2]
5. Keep and share copies. It is common practice to keep the original somewhere safe and give copies to your agent and your doctor. Some people also add a Texas living will, which is a separate document.

The FormsPal template has no lines for the witnesses’ names or signatures, only a printed note under your signature line that repeats the two-witness rule. Ask a lawyer or the notary how to record the witnesses’ signatures before you sign.

Common Mistakes to Avoid

Most problems with a medical power of attorney come from skipped steps, not from the blanks on the form. These are the mistakes to watch for, based on the rules earlier on this page and on the way the template is built.

• Signing alone, when the principal must sign in the presence of two witnesses unless a notary public acknowledges the signature instead.^[1.2]
• Naming an agent in a barred role, such as your health care provider or your residential care provider, who may not exercise the authority of an agent while serving in that role.^[1.1]
• Choosing witnesses without checking whether they qualify under section 166.003.^[1.2]
• Skipping Part II, which states your end-of-life wishes and deserves a careful reading before you sign.
• Looking for witness lines on the template, which has none, so a lawyer or the notary should explain how to record the witnesses’ signatures.
• Leaving the only copy in a drawer, when it is common practice to give copies to your agent and your doctor.

Other Texas Forms
Different printable Texas templates readily available for download here and that can be modified in our simple document constructor.

• Texas Last Will
• Texas Living Will
• Texas Small Estate Affidavit
• Texas Bill of Sale
• Texas Rental Lease Agreement
• Texas Eviction Notice

Download a Free Texas Medical Power of Attorney Form

You can download the Texas medical power of attorney as a PDF with 21 fillable fields, or build it online and print it. Either way, you still need to sign it the way Texas requires, before two witnesses or a notary public.

Create a free high quality Texas Medical Power of Attorney online now!

Create and Print Online Now

General information, not legal or tax advice. Talk to a lawyer or your doctor about your own situation.

Sources

1. Texas Legislature Online. Texas Family Code §§ 166.153 to 166.154.
   • 1.1 Tex. Health and Safety Code Section 166.153
   • 1.2 Tex. Health and Safety Code Section 166.154
   • 1.3 Tex. Health and Safety Code Section 166.154(c)
   • 1.4 Tex. Health and Safety Code Section 166.152
2. Tex. Health and Safety Code § 166.003. Accessed October 15, 2026.
   • 2.1 Tex. Health and Safety Code Section 166.003(2)

Mara Erlach

Writer & Attorney

Mara has been practicing estate planning and trust law in California since 2003, taking pride in helping clients of all backgrounds and asset profiles form a complete and customized estate plan. Her specialties are: estate planning, wills and trusts, trust and probate administration.