Fillable Tennessee Durable Power Of Attorney For Health Care printable pdf download

TENNESSEE

Durable Power of Attorney For Health Care

Warning To Person Executing This Document

This is an important legal document. Before executing this document, you should know these important facts.

This document gives the person you designate as your agent (the attorney-in-fact) the power to make healthcare decisions for you. Your agent must act

consistently with your desires as stated in this document.

Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping

treatment necessary to keep you alive.

Notwithstanding this document, you have the right to make medical or other healthcare decisions for yourself so long as you can give informed consent with

respect to particular decisions. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be

stopped or withheld if you object at the time.

This document gives your agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain,

diagnose or treat a physical or mental condition. This power is subject to any limitations that you include in this 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 of your agent to make healthcare decisions for you if your agent: (1)

authorizes anything that is illegal, or (2) acts contrary to your desires as stated in this document.

You have the right to revoke the authority of your agent by notifying your agent or treating physician, hospital or other healthcare provider orally or in writing of

the revocation.

Your agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document.

Unless you otherwise specify in this document, this document gives your agent the power after you die to: (1) authorize an autopsy, (2) donate your body or

parts thereof to transplant or therapeutic or educational or scientific purposes, and (3) direct the disposition of your remains.

If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.

I hereby appoint

* as my attorney-in-fact to make healthcare decisions for

me if, and only if, I am incapacitated or otherwise unable to make such decisions for myself.

My attorney-in-fact has received an executed copy of this document, and has agreed to serve as my attorney-in-fact for healthcare decisions consistent with my

directions herein expressed.

If at any time I should have a terminal condition, or be in an irreversible coma or persistent vegetative state, and my attending physician or other healthcare

provider has determined that there can be no recovery from such condition or state, where the application of life-prolonging procedures (including, but not limited

to, mechanical breathing devices, cardiopulmonary resuscitation, and artificial nutrition and hydration) would serve only to prolong the condition or state, my

attorney-in-fact is specifically directed to direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally, with only the administration

of medications or the performance of any medical procedure deemed necessary to provide me with comfortable care.

My attorney-in-fact shall have full authority to donate all or any part of my body, authorize an autopsy and direct the disposition of my remains.

My attorney-in-fact shall have the right to examine my medical records and to consent to their disclosure. I grant my attorney-in-fact the power and authority to

execute on my behalf any waiver, release or other document which may be necessary in order to implement the healthcare decisions that this instrument

authorizes my attorney-in-fact to make on my behalf.

In the event the above-named attorney-in-fact should for any reason be unable or unwilling to serve as my attorney-in-fact under this instrument, I appoint

* to serve in such capacity. This individual also has been furnished with a copy of this

document, and has agreed to serve as my alternate attorney-in-fact.

This instrument is to be construed and interpreted as a durable power of attorney for health care and is intended to comply in all respects with the provisions of

Tennessee Code Annotated, Sections 34-6-201 et seq.; and all terms used in this instrument shall have the meanings set forth for such terms in the statute, unless

otherwise specifically defined herein. This durable power of attorney for health care revokes any prior durable power of attorney for health care executed by me.

Dated this

day of

, in the year

*Print name, address, and telephone number

Signature of Principal

We, the undersigned witnesses, declare under penalty of perjury under the law of Tennessee, that

is personally

known to us to be the principal; that the principal signed and acknowledged this Durable Power of Attorney for Health Care in our presence; that the principal

appears to be of sound mind and under no duress, fraud, or undue influence; that neither of us is the person appointed as attorney-in-fact by this instrument; and

that neither of us is a healthcare provider, an employee of a healthcare provider, the operator of a healthcare institution, or an employee of an operator of a

healthcare institution. We further declare under penalty of perjury under the laws of Tennessee that we are not related to the principal by blood, marriage, or

adoption; and that, to the best of our knowledge, we are not entitled to any part of the principal’s estate upon the death of the principal under any will or codicil of the

principal existing as of the date of this instrument, or by operation of any existing law.

Signature of Witness

STATE OF TENNESSEE

COUNTY OF

Signature of Witness

On this

day of

in the year

, before the undersigned Notary Public, personally appeared

personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged

that

executed it. I declare under penalty of perjury that the person whose name is subscribed to this instrument

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

Notary Public

My commission Expires: