Fillable Durable Power Of Attorney For Health Care Form (Page 2 of 2) in pdf

Witnesses Statement

By signing this paper, each witness is saying that : “I know the person who signed this paper and asked

me to be a witness. This person is an adult. This person signed the paper in front of me. I believe this

person is in their right mind and knows what they are signing. I believe no one forced this person to

sign the paper. I believe no one talked this person into signing this paper. This person understands

what will happen because they signed this paper. I am not related to this person by blood, marriage

or adoption. I will not get any of their estate when they die. I am not the person this paper makes the

attorney in fact. I am not the attending doctors. I do not work for the doctor or a health facility where

the person signing this paper is a patient. I do not now have a claim against any of this person’s estate

when they die.”

__________________________________________

____________________________________________

Signature of Witness

Date: ______________

STATE OF TENNESSEE

COUNTY OF _______________________

Subscribed, sworn to and acknowledged before me by ____________________________________, the

principal, and subscribed and sworn to before me by ____________________________________ and

____________________________________, witnesses, this _____ day of ______________, 20___.

____________

_______________________________

My commission expires: ________________

Notary Public

- WARNING -

document. You may state in this document any types of treatment

that you do not desire. In addition, a court can take away the power

This is an important legal document. Before executing this docu-

of your agent to make health care decisions for you if your agent: (1)

ment you should know these important facts:

authorizes anything that is illegal; or (2) acts contrary to your desires

as stated in this document.

This document gives the person you designate as your agent

(your attorney in fact) the power to make health care decisions for

You have the right to revoke the authority of your agent by noti-

you. Your agent must act consistently with your desires as stated in

fying your agent or your treating physician, hospital or other health

this document.

care provider orally or in writing of the revocation.

Except as you otherwise specify in this document, this docu-

Your agent has the right to examine your medical records and to

ment gives your agent the power to consent to your doctor not giving

consent to their disclosure unless you limit this right in this docu-

treatment or stopping treatment necessary to keep you alive.

ment.

Notwithstanding this document, you have the right to make

Unless you otherwise specify in this document, this document

medical and other health care decisions for yourself so long as you

gives your agent the power after you die to: (1) authorize an autopsy;

can give informed consent with respect to the particular decision. In

(2) donate your body or parts thereof for transplant or therapeutic or

addition, no treatment may be given to you over your objection, and

educational or scientific purposes; and (3) direct the disposition of

health care necessary to keep you alive may not be stopped or with-

your remains.

held if you object at the time.

If there is anything in this document that you do not under-

This document gives your agent authority to consent, to refuse

stand, you should ask an attorney to explain it to you.

to consent, or to withdraw consent to any care, treatment, service, or

procedure to maintain, diagnose or treat a physical or mental condi-

[Tennessee Code Annotated, § 34-6-205; Durable Power of

tion. This power is subject to any limitations that you include in this

Attorney for Health Care]

Durable Power of Attorney for Health Care p. 2 of 2

5/04 LEGAL AID SOCIETY OF MIDDLE TENNESSEE AND THE CUMBERLANDS

Durable Power Of Attorney For Health Care Form Page 2

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