$23.95

Add to cart

Tennessee _____________________________________________________________ Notary Public My Commission Expires: __________________________ 3 _________, the declarant, and subscribed and sworn to before me by ________________________________ and _____________________________________, witnesses, this ______ day of ____________, 20____. __________________________________________________________ Witness STATE OF TENNESSEE ) ) ) COUNTY OF _____________________ ) Subscribed, sworn to and acknowledged before me by ________________________the 2 present time, have a claim against any portion of the estate of the declarant upon the declarant's death. _________________________________________________________________ Witness ___________ion of law then existing; that we are not the attending physician, an employee of the attending physician or a health facility in which the declarant is a patient; and that we are not persons who, at he declarant by blood or marriage; that we are not entitled to any portion of the estate of the declarant upon the declarant's decease under any will or codicil thereto presently existing or by operatclarant, an adult, whom we believe to be of sound mind, fully aware of the action taken herein and its possible consequence. We, the undersigned witnesses, further declare that we are not related to t____________________________________________________ Declarant's Signature We, the subscribing witnesses hereto, are personally acquainted with and subscribe our names hereto at the request of the deand I am emotionally and mentally competent to make this declaration. In acknowledgment whereof, I do hereinafter affix my signature on this the ___________ day of ____________, 20_____ ____________________________________________________________________________________ ____________________________________________________________________________ I understand the full import of this declaration, INSTRUCTIONS (optional ­ or cross out): ____________________________________________________________________________ ____________________________________________________________________________ _____ and accept the consequences of such refusal. The definitions of terms used herein shall be as set forth in the Tennessee Right to Natural Death Act, Tennessee Code Annotated, § 32-11-103. ADDITIONALlity to give directions regarding my medical care, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical care_________________________________. (Insert specific organs and/or tissues for transplantation) ____________ DO NOT desire to donate my organs or tissues for transplantation. In the absence of my abins and/or tissues. By checking the appropriate line below, I specifically: ____________ Desire to donate my organs and/or tissues for transplantation. 1 ____________ Desire to donate my ____________rmined dead according to Tennessee Code Annotated, § 68-3-501(b), to maintain me on artificial support systems only for the period of time required to maintain the viability of and to remove such orgaated below I have expressed my desire to donate my organs and/or tissues for transplantation, or any of them as specifically designa ted herein, I do direct my attending physician, if I have been deteided food, water or other nourishment or fluids. ORGAN DONOR CERTIFICATION: Notwithstanding my previous declaration relative to the withholding or withdrawal of lifeprolonging procedures, if as indic_________ Authorize the withholding or withdrawal of artificially provided food, water or other nourishment or fluids. ____________ DO NOT authorize the withholding or withdrawal of artificially prov medical procedure deemed necessary to provide me with comfortable care or to alleviate pain. ARTIFICIALLY PROVIDED NOURISHMENT AND FLUIDS: By checking the appropriate line below, I specifically: ___ustaining life, or the life process, I direct that medical care be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medications or the performance of anyo reasonable medical expectation of recovery and which, as a medical probability, will result in my death, regardless of the use or discontinuance of medical treatment implemented for the purpose of sall not be artificially prolonged under the circumstances set forth below, and do hereby declare: If at any time I should have a terminal condition and my attending physician has determined there is naimers and Terms of Use found at findlegalforms.com Living Will DECLARATION I, _______________________________________________________, willfully and voluntarily make known my desire that my dying shng with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclarting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealilegal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a strd by the attending physician. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their declarant, dated and signed by the declarant. (2) By oral statement or revocation made by the declarant to the attending physician. Such revocation shall be made a part of the declarant's medical recoental state or competency, by any of the following methods, effectively communicated by the declarant to the attending physician or other concerned health care provider: (1) Written revocation by the to accept, refuse, or withdraw medical care. (form included below) 32-11-106. Revocation of declaration. A declaration may be revoked at any time by the declarant, without regard to the declarant's mof the declarant's medical record. 32-11-105. Form of declaration. The declaration may be substantially in the following form, but not to the exclusion of other written and clear expressions of intenttending physician and/or other Living Information & Instructions ­ Page 3 concerned health care provider. An attending physician who is so notified shall make the declaration, or a copy of it, part ntially in the form established in § 32-11-105. (b) It is the responsibility of the declarant or someone acting on the declarant's behalf to deliver a copy of such living will or declaration to the at physician nor an employee of a health facility in which the declarant is a patient, and neither of them has a claim against any portion of the estate of the declarant. The declaration shall be substathe declarant's demise under any will or codicil thereto made by the declarant. In addition, the witnesses shall verify that neither of them is the attending physician nor an employee of the attending witnesses who shall verify in such declaration that they are not related to the declarant by blood or marriage, and that they would not be entitled to any portion of the estate of the declarant upon the withholding or withdrawal of medical care to such person, to become effective on loss of competency, which declaration shall be acknowledged and signed by the declarant in the presence of two (2)n of death pursuant to § 68-3-501(b)(1), and following removal from artificial support systems. 32-11-104. Execution of declaration. (a) Any competent adult person may execute a declaration directing use or discontinuance of medical treatment implemented for the purpose of sustaining life, or the life processes; and (10) "Tissue donation" means a procedure to recover tissue following a declaratiote, sustained by any human being, from which there is no reasonable medical expectation of recovery and which, as a medical probability, will result in the death of such human being, regardless of the to practice medical care under title 63, chapters 6 and 9; (9) "Terminal condition" means any disease, illness, injury or condition, including, but not limited to, a coma or persistent vegetative sta. These also include, but are not limited to, sedatives and pain-killing drugs, nonartificial oral feeding, suction, hydration and hygienic care; (8) "Physician" means any person licensed or permitted, but prior to removal from artificial support systems; and (7) "Palliative care" includes any measure taken by a physician or health care provider designed primarily to maintain the patient's comfortal of artificially provided food, water or other nourishment or fluids"; (6) "Organ donation" means a procedure to recover vascular organs following a declaration of death pursuant to § 68-3-501(b)(2)the provisions of the instrument which creates a living will or durable power of attorney for health care include the following or substantially the following: "I authorize the withholding or withdrawe or supplant vital body function. This part shall not be interpreted to allow the withholding or withdrawal of simple nourishment or fluids so as to condone death by starvation or dehydration unless ing of nourishment, hydration or other basic nutrients, regardless of the method used; radiation therapy; or any other medical act designed for diagnosis, assessment or treatment or to sustain, restore include, but are not limited to: surgery; drugs; transfusions; mechanical ventilation; dialysis; Living Information & Instructions ­ Page 2 cardiopulmonary resuscitation; artificial or forced feedation and body disposal; (5) "Medical care" includes any procedure or treatment rendered by a physician or health care provider designed to diagnose, assess or treat a disease, illness or injury. Thes4) "Living will" means a written declaration, pursuant to this chapter, stating declarant's desires for medical care or non-care, including palliative care, and other related matters such as organ don provisions of this chapter; (3) "Health care provider," "health care facility" or "health facility" means a person, facility or institution licensed or authorized to provide health or medical care; (an individual who is able to understand and appreciate the nature and consequences of a decision to accept or refuse treatment; (2) "Declarant" means an individual who declares a living will under theclaration, called a "living will," as hereinafter provided. 32-11-103. Definitions. The following definitions shall govern the construction and operation of this chapter: (1) "Competent person" means ntation and to provide mechanisms for ind ividuals to express their desire to donate their organs and/or tissues. (b) The general assembly does further empower the exercise of this right by written deliative care and the use of extraordinary procedures and treatment. The general assembly further declares that it is in the public interest to facilitate recovery of organs and/or tissues for transplawith as much dignity as circumstances permit and to accept, refuse, withdraw from, or otherwise control decisions relating to the rendering of the person's own medical care, specifically including pal to Living Wills. 32-11-102. Legislative intent. (a) The general assembly declares it to be the law of the state of Tennessee that every person has the fundamental and inherent right to die naturally ing Will. This Tennessee Living Will is based on Tennessee Statutes Title 32 Chapter 11 Section 102 et. Seq. For your convenience, we have included useful excerpts from the Tennessee Statutes relating____________________________ (Notary Public) -3- Information and Instructions Tennessee Living Will This package contains (1) Information and Instruction for Tennessee Living Will; (2) Tennessee Liv________, the declarant, and subscribed and sworn to before me by ______________________________ and_____________________________________, witnesses, this ______ day of ____________, 20_____. _______d name: __________________________________________________ Address: ______________________________________________________ Subscribed, sworn to and acknowledged before me by _________________________nted name: __________________________________________________ Address: ______________________________________________________ Second witness' signature: _______________________________________ Printee estate of the principal upon the death of the principal under a will or codicil thereto now existing, or by operation of law. First witness' signature: _________________________________________ Prie, I do not, at the present time, have a claim against any portion of the estate of the principal upon the principal's death; and that, to the best of my knowledge, I am not entitled to any part of thof a health care institution nor an employee of an operator of a health care institution; that I am not related to the principal by blood, marriage, or adoption; that, to the best of my -2- knowledgno duress, fraud or undue influence; that I am not the person appointed as attorney in fact by this document; that I am not a health care provider, an employee of a health care provider, the operator o signed this document is personally known to me to be the principal; that the principal signed this durable power of attorney in my presence; that the principal appears to be of sound mind and under his ____ day of__________, 20 ____. ___________________________________ (Signature of Principal) WITNESS DECLARATION I declare under penalty of perjury under the laws of Tennessee that the person why own medical decisions is to be made by my attorney- in-fact, or if he or she is unable, unwilling or unavailable to act, by my alternate attorney- in- fact. IN WITNESS WHEREOF, I have set my hand t power of attorney becomes effective when I can no longer make my own medical decisions and shall not be affected by my subsequent disability or incompetence. The determination of whether I can make mlaw) for me, including decisions to withhold or withdraw any form of life support. I expressly authorize my agent (and alternate agent) to make decisions for me about tube feeding and medication. Thise attorney- in-fact) I have discussed my wishes with my attorney- in- fact and my alternate attorney-in- fact, and authorize him/her to make all and any health care decisions (as defined by Tennessee _________________ (name of alternate attorney- in-fact) of _______________________________________________ _________________________________________________________. (address and telephone of alternats with respect to medical treatment. In the event the person I appoint above is unable, unwilling or unavailable to act as my health care agent, I hereby appoint: ________________________________________ (address and telephone of attorney- in- fact) as my attorney- in- fact to have the authority hereinafter set forth in order to express and carry out my specific and general instructions and desire executing this document. I hereby appoint: ____________________________________________________________ (name of attorney- infact) of _________________________________________________________________f __________________________________________________________, (address) state and affirm that I am an adult of sound mind and have read the foregoing paragraphs concerning the legal consequences of myn this document that you do not understand, you should ask an attorney to explain it to you. -1- Power of Attorney I, _________________________________________________________, (name of principal) o 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 il 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)thority 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 medicaagent 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 auwer 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 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 poicular 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 sary 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 partesires 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 necesw 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 d of Use found at findlegalforms.com -5- Power of Attorney for Health Care WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal Document. Before executing this document you should knoh another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Termst. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated witte for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney firsr express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitumay be terminated or revoked only pursuant to this section and shall not be affected by the existence of a living will executed by the principal. [_] These forms are provided "as is" and no implied o power of attorney unless the person has actual knowledge of the revocation. (g) The authority of an attorney in fact acting under a durable power of attorney for health care as provided in this part ted by a durable power of attorney for health care is revoked under this section, a person is not subject to criminal prosecution or civil liability for acting in good faith reliance upon such durablerriage is dissolved or annulled, the dissolution or annulment revokes any designation of the former spouse as an attorney in fact to make health care decisions for the principal. (f) If authority granattorney for health care. -4- (e) Unless the durable power of attorney for health care expressly provides otherwise, if after executing a durable power of attorney for health care the principal's maor health care. This presumption is a presumption affecting the burden of proof. (d) Unless it provides otherwise, a valid durable power of attorney for health care revokes any prior durable power of al's medical records and shall make a reasonable effort to notify the attorney in fact of the revocation. (c) It is presumed that the principal has the capacity to revoke a durable power of attorney fre provider orally or in writing that the authority granted to the attorney in fact to make health care decisions is revoked, the health care provider shall make the notification a part of the principiting; or (2) Revoke the authority granted to the attorney in fact to make health care decisions by notifying the health care provider orally or in writing. (b) If the principal notifies the health caorney for health care, do any of the following: (1) Revoke the appointment of the attorney in fact under the durable power of attorney for health care by notifying the attorney in fact orally or in wrocument shall not affect the validity of the document (see enclosed notice found at the beginning of the document): 34-6-207. Revocation. (a) The principal may, after executing a durable power of att the principal prepares a durable power of attorney for health care for the principal, the document shall contain the following warning statement. The failure to include the warning statement in the dade by the attorney in fact permitting the principal to die naturally with only the administration of palliative care as defined in § 32-11-103(6). 34-6-205. Warning Statement. If a person other thanf attorney may make health care decisions as provided in this part for the principal who has a terminal condition as defined in § 32-11103(9). The decision to withhold or withdraw health care may be mthe making of health care decisions on behalf of the principal. (d) Subject to any limitations in the durable power of attorney for health care, the attorney in fact designated in such durable power otitle 68, chapter 4. (c) Nothing in this part affects any right the person designated as attorney in fact may have, apart from the durable power of attorney for health care, to make or participate in mpiled in title 68, chapter 30; -3- (2) Authorizing an autopsy pursuant to the Post Mortem Examination Act, compiled in title 38, chapter 7; and (3) Directing the disposition of remains pursuant to me extent as the principal could make health care decisions for such principal if the principal had the capacity to do so, including: (1) Making a disposition under the Uniform Anatomical Gift Act, cor of attorney for health care, the attorney in fact designated in such durable power of attorney may make health care decisions for the principal, before or after the death of the principal, to the saof Attorney Act, compiled in part 1 of this chapter, which authorizes the fiduciary to revoke or amend a power of attorney created by the princ ipal. (b) Subject to any limitations in the durable powent; nor (ii) Replace the attorney in fact designated in such durable power of attorney. (B) The provisions of this subdivision (a)(2) apply notwithstanding the provisions of the Uniform Durable Power rdian of the estate, or other fiduciary, such fiduciary shall not have the power to: (i) Revoke or amend the durable power of attorney for health care executed by the principal prior to such appointmee principal in all matters of health care decisions. (2) (A) If, following the execution of a durable power of attorney for health care, a court of the principal's domicile appoints a conservator, guain fact designated in such durable power of attorney who is known to the health care provider to be available and willing to make health care decisions has priority over any other person to act for thre provides otherwise, or unless a court with appropriate jurisdiction finds by clear and convincing evidence that the attorney in fact is acting on behalf of the principal in bad faith, the attorney y blood, marriage or adoption; and (2) The other requirements of this part are satisfied. 34-6-204. Attorney in fact - Powers - Limitations. (a) (1) Unless the durable power of attorney for health canstitution may be designated as the attorney in fact to make health care decisions under a durable power of attorney for health care if: (1) The employee so designated is a relative of the principal bthe time of execution of the durable power of attorney or by operation of law then existing. -2- (f) An employee of the treating health care provider or an employee of an operator of a health care iod, marriage or adoption; or (2) A person who would be entitled to any portion of the estate of the principal upon the principal's death under any will or codicil thereto of the principal existing at e of a health care institution. (e) At least one (1) of the persons used as a witness under subsection (a) shall be a person who is not one (1) of the following: (1) A relative of the principal by blo under subsection (a): (1) A health care provider; (2) An employee of a health care provider; (3) The person named as attorney in fact; (4) The operator of a health care institution; or (5) An employef signing or not signing this power of attorney, and my client, after being so advised, has executed this durable power of attorney for health care." (d) None of the following may be used as a witness client at the time this power of attorney was executed. I have advised my client concerning my client's rights in connection with this power of attorney and the applicable law, and the consequences oney representing the conservatee signs a certificate stating in substance: "I am an attorney authorized to practice law in the state where this power of attorney was executed, and the principal was my this state where the conservatee has the power to execute legal documents, unless: (1) The power of attorney is otherwise valid; (2) The conservatee is represented by legal counsel; and (3) The attor A conservator may not be designated as the attorney in fact to make health care decisions under a durable power of attorney for health care executed by a person who is a conservatee under the laws of provider or employee of a health care provider may not act as an attorney in fact to make health care decisions if the health care provider becomes the principal's treating health care provider. (c)loyee of an operator of a health care institution may be designated as the attorney in fact to make health care decisions under a durable power of attorney for health care; and -1- (2) A health care." (b) Except as provided in subsection (f): (1) Neither the treating health care provider nor an employee of the treating health care provider, nor an operator of a health care institution nor an empand that, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will or codicil thereto now existing, or by operation of lawrincipal by blood, marriage, or adoption; that, to the best of my knowledge, I do not, at the present time, have a claim against any portion of the estate of the principal upon the principal's death; not a health care provider, an employee of a health care provider, the operator of a health care institution nor an employee of an operator of a health care institution; that I am not related to the ptorney in my presence; that the principal appears to be of sound mind and under no duress, fraud or undue influence; that I am not the person appointed as attorney in fact by this document; that I am declare under penalty of perjury under the laws of Tennessee that the person who signed this document is personally known to me to be the principal; that the principal signed this durable power of atry public by the principal and is signed by at least two (2) witnesses who witnessed the signing of the instrument by the principal, with each witness making the following declaration in substance: "Idate of its execution; and (3) The durable power of attorney for health care is executed by the following method: the durable power of attorney for health care is signed and acknowledged before a notasfied: (1) The durable power of attorney for health care specifically authorizes the attorney in the fact to make health care decisions; (2) The durable power of attorney for health care contains the ealth Care Form. 34-6-203. Requirements. (a) An attorney in fact under a durable power of attorney for health care may not make health care decisions unless all of the following requirements are satior Health Care is based on Title 34 Chapter 6 Section 34-6207 of the Tennessee Statutes. The following are useful excerpts from the Tennessee Statutes relating to the Tennessee Power of Attorney for Hlth Care This package contains (1) Information and Instruction for Tennessee Power of Attorney for Health Care; (2) Tennessee Power of Attorney for Health Care Form. This Tennessee Power of Attorney fssed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Power of Attorney for Heafits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discu advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it e been made or are provided as to their suitability for any specific purpose or as to their legal effect or comp leteness. [_]These forms are not intended and are not a substitute for legal and/or taxce Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties havTennessee Advance Health Care Directive This package contains both a Tennessee Power of Attorney for Health Care and a Tennessee Living Will. Together these forms are also sometimes known as an Advan Tennessee