This Tennessee Medical Power of Attorney is prepared in accordance with the Tennessee Durable Power of Attorney for Health Care Act. It grants the person(s) named below the authority to make healthcare decisions on behalf of the individual establishing the power of attorney when they are unable to communicate or make decisions for themselves.
Principal Information:
- Full Name: ___________________________
- Date of Birth: ___________________________
- Address: ___________________________
- City: _____________, State: Tennessee, Zip Code: ___________
- Phone Number: ___________________________
Agent Information:
- Primary Agent Full Name: ___________________________
- Relationship to Principal: ___________________________
- Address: ___________________________
- City: _____________, State: ___________, Zip Code: ___________
- Phone Number: ___________________________
Alternate Agent Information (If Primary Agent is unable or unwilling to act):
- Full Name: ___________________________
- Relationship to Principal: ___________________________
- Address: ___________________________
- City: _____________, State: ___________, Zip Code: ___________
- Phone Number: ___________________________
General Powers Granted:
- The agent is authorized to make any and all health care decisions on my behalf that I could make if competent and able to do so, subject to any limitations set forth herein.
- This authority includes, but is not limited to, the power to give or refuse consent for any care, treatment, service, or procedure to maintain, diagnose, treat, or provide for my physical or mental health.
- The agent's authority is effective immediately and will continue to be effective even if I become disabled, incapacitated, or incompetent.
Special Instructions/Limitations:
_________________________________________________________________________
_________________________________________________________________________
Organ Donation:
- ___ I wish to donate my organs, tissues, or eyes in the event of my death.
- ___ I do not wish to donate my organs, tissues, or eyes in the event of my death.
- If organ donation is desired, specific organs: ___________________________
Signatures:
The Principal and Agents must sign and date this document in the presence of two witnesses, who must also sign and date. This document must also be notarized to be legally binding.
Principal's Signature: ___________________________ Date: ___________
Primary Agent's Signature: ___________________________ Date: ___________
Alternate Agent's Signature: ___________________________ Date: ___________
First Witness's Signature: ___________________________ Date: ___________
Second Witness's Signature: ___________________________ Date: ___________
Notary Public:
State of Tennessee
County of ___________
Subscribed and sworn to (or affirmed) before me on ___________ (date), by ___________________________ (name(s) of principal and agents), who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument, the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal:
___________________________ (Notary Seal)
Notary Public Signature: ___________________________
My commission expires: ___________