Form Ph-4194 - Advance Care Plan Page 2
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2ADVANCED CARE PLAN
Page 2 of 2
Other instructions, such as burial arrangements, hospice care, etc.: __________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
(Attach additional pages if necessary)
Organ donation: Upon my death, I wish to make the following anatomical gift (mark one):
Any organ/tissue
My entire body
Only the following organs/tissues: ______________________
__________________________________________________________________________________________________________________
No organ/tissue donation
SIGNATURE
Your signature must either be witnessed by two competent adults or notarized. If witnessed, neither witness may be the person you appointed as
your agent or alternate, and at least one of the witnesses must be someone who is not related to you or entitled to any part of your estate.
Signature: ___________________________________________________
DATE: ____________________________________________
(Patient)
Witnesses:
1. I am a competent adult who is not named as the agent. I witnessed the
patient’s signature on this form.
Signature of witness number 1
2. I am a competent adult who is not named as the agent. I am not related
to the patient by blood, marriage, or adoption and I would not be
Signature of witness number 2
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.
This document may be notarized instead of witnessed:
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 who signed 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.
Notary Public:___________________________________
Signature
My commission expires:___________________________
WHAT TO DO WITH THIS ADVANCE DIRECTIVE
•
Provide a copy to your physician(s)
•
Keep a copy in your personal files where it is accessible to others
•
Tell your closest relatives and friends what is in the document
•
Provide a copy to the person(s) you named as your health care agent
PH-4194
RDA – n/a
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Parent category: Medical