Appointment Of Health Care Agent, Form Ph-4194 - Advance Care Plan

Download a blank fillable Appointment Of Health Care Agent, Form Ph-4194 - Advance Care Plan in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Appointment Of Health Care Agent, Form Ph-4194 - Advance Care Plan with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

APPOINTMENT OF HEALTH CARE AGENT

(Tennessee)

I, _________________________________, give my agent named below permission to make health care

decisions for me if I cannot make decisions for myself, including any health care decision that I could have made

for myself if able. If my agent is unavailable or is unable or unwilling to serve, the alternate named below will take

the agent’s place.

Agent:

Alternate:

Name

Address

City

State

Zip Code

City

State

Zip Code

(

)

(

)

Area Code

Home Phone Number

Area Code

Home Phone Number

(

)

(

)

Area Code

Work Phone Number

Area Code

Work Phone Number

(

)

(

)

Area Code

Mobile Phone Number

Area Code

Mobile Phone Number

Patient’s name (please print or type)

Date

Signature of patient (must be at least 18 or emancipated minor)

To be legally valid, either block A or block B must be properly completed and signed.

---------------------------------------------------------------------------------------------------------------------------------------------------------

Block A

Witnesses (2 witnesses required)

1. I am a competent adult who is not named above.

I witnessed the patient’s signature on this form.

Signature of witness number 1

2. I am a competent adult who is not named above. I am not

related to the patient by blood, marriage, or adoption and I

Signature of witness number 2

would not be entitled to any portion of the patient’s estate upon

his or her death under any existing will or codicil or by operation

of law. I witnessed the patient’s signature on this form.

---------------------------------------------------------------------------------------------------------------------------------------------------------

Block B

Notarization

STATE OF TENNESSEE

COUNTY OF

I am a Notary Public in and for the State and County named above. The person who signed this instrument is personally known to me (or

proved to me on the basis of satisfactory evidence) to be the person whose name is shown above as the “patient.” The patient personally

appeared before me and signed above or acknowledged the signature above as his or her own. I declare under penalty of perjury that the

patient appears to be of sound mind and under no duress, fraud, or undue influence.

My commission expires:

Signature of Notary Public

Approved by Tennessee Department of Health, Board for Licensing Health Care Facilities, February 3, 2005