Tennessee Durable Power of Attorney for Health Care

INFORMATION CONCERNING DURABLE POWER OF ATTORNEY FOR HEALTH CARE

Tenn. Code Ann. § 34-6-201 et seq.

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 health care 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 and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. 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 health care 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 your treating physician, hospital or other health care 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 for 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 an attorney to explain it to you.

THIS POWER OF ATTORNEY IS NOT VALID UNLESS:

(1) YOU SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC; OR

(2) YOU SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES WHO MEET THE FOLLOWING CRITERIA.

THE FOLLOWING RESTRICTIONS EXIST AS TO WHO MAY WITNESS YOUR SIGNING THIS POWER OF ATTORNEY:

(1) The person you have designated as your agent may not serve as a witness.

(2) Both of your witnesses must be at least 18 years of age or older.

(3) At least one of your witnesses may not be a person related to you by blood, marriage, or adoption and may not be a person entitled to any part of your estate after your death under a will or codicil executed by you or by operation of law.

I HAVE RECEIVED THE ABOVE DISCLOSURE AND HAVE READ AND UNDERSTAND ITS CONTENTS.

Date: ____________________________

Signature: ____________________________________________________

Print Name: __________________________________________________

TENNESSEE DURABLE POWER OF ATTORNEY FOR HEALTH CARE

Tenn. Code Ann. § 34-6-201 et seq.

I, __________________________________________________________

(insert your name)

Name: ______________________________________________________________

Address: __________________________________________________________

Phone: ____________________________

Mobile: ___________________________

as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. This medical power of attorney takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician.

LIMITATIONS ON THE DECISION-MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

DESIGNATION OF ALTERNATE AGENT.

(You are not required to designate an alternate agent, but you may do so. An alternate agent may make the same health care decisions as the designated agent if the designated agent is unable or unwilling to act as your agent. If the agent designated is your spouse, the designation shall terminate if your marriage is dissolved.)

If the person designated as my agent is unable or unwilling to make health care decisions for me, I designate the following persons to serve as my agent to make health care decisions for me as authorized by this document, who serve in the following order:

A. First Alternate Agent

Name: ______________________________________________________________

Address: __________________________________________________________

Phone: ____________________________

Mobile: ___________________________

B. Second Alternate Agent

Name: ______________________________________________________________

Address: __________________________________________________________

Phone: ____________________________

Mobile: ___________________________

The original of this document is kept at:

________________________________________________________________

________________________________________________________________

________________________________________________________________

The following individuals or institutions have signed copies:

Name: ______________________________________________________________

Address: __________________________________________________________

Phone: ____________________________

Mobile: ___________________________

Name: ______________________________________________________________

Address: __________________________________________________________

Phone: ____________________________

Mobile: ___________________________

DURATION.

I understand that this power of attorney exists indefinitely from the date I execute this document unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent continues to exist until the time I become able to make health care decisions for myself.

(IF APPLICABLE)

This power of attorney ends on the following date: ________________________________

PRIOR DESIGNATIONS REVOKED.

I revoke any prior medical power of attorney.

ACKNOWLEDGMENT OF DISCLOSURE STATEMENT.

I have been provided with a warning statement explaining the effect of this document. I have read and understand that information contained in the warning statement.

SIGNATURE ACKNOWLEDGED BEFORE NOTARY

I sign my name to this medical power of attorney on ____________

Day: ____________

Month and year: ___________________________________

City and State: _____________________________________________

Signature: ____________________________________________________

Print Name: __________________________________________________

State of Tennessee

County of ____________________________

This instrument was acknowledged before me on (date): _______________________

Name of person acknowledging: ______________________________________

Notary Public, State of Tennessee — Signature: _______________________________

Notary's printed name: __________________________________________

My commission expires: __________________________________________

OR — YOU MAY INSTEAD SIGN IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES.

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY. YOU MAY SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC OR YOU MAY SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES.)

SIGNATURE IN PRESENCE OF TWO COMPETENT ADULT WITNESSES

STATEMENT OF FIRST WITNESS (MAY NOT BE RELATED TO THE PRINCIPAL)

As required under Tenn. Code Ann. § 34-6-203, I attest that I am a competent adult (at least 18 years of age), and I am not the person appointed as agent by this document. I am not related to the principal by blood, marriage, or adoption. I would not be entitled to any portion of the estate of the principal upon the death of the principal under any will or codicil made by the principal existing at the time of execution of this durable power of attorney for health care or by operation of law.

Signature: ____________________________________________________

Print Name: __________________________________________________

Date: ____________________________

Address: _______________________________________________________

STATEMENT OF SECOND WITNESS (MAY BE RELATED TO THE PRINCIPAL)

As required under Tenn. Code Ann. § 34-6-203, I attest that I am a competent adult (at least 18 years of age), and I am not the person appointed as agent by this document.

Signature: ____________________________________________________

Print Name: __________________________________________________

Date: ____________________________

Address: _______________________________________________________