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Tennessee day of ____________, 20_____. ___________________________________ (Notary Public) -3- before me by _________________________________, the declarant, and subscribed and sworn to before me by ______________________________ and_____________________________________, witnesses, this ______________________________________ Printed name: __________________________________________________ Address: ______________________________________________________ Subscribed, sworn to and acknowledged____________________________________ Printed name: __________________________________________________ Address: ______________________________________________________ Second witness' signature: _______edge, 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 law. First witness' signature: _____on; that, to the best of my -2- 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; and that, to the best of my knowle 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 principal by blood, marriage, or adoptipal 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 not a health care provider, an employer 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 attorney in my presence; that the princit. IN WITNESS WHEREOF, I have set my hand this ____ day of__________, 20 ____. ___________________________________ (Signature of Principal) WITNESS DECLARATION I declare under penalty of perjury undeence. The determination of whether I can make my 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-fac for me about tube feeding and medication. This 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 incompethealth care decisions (as defined by Tennessee law) for me, including decisions to withhold or withdraw any form of life support. I expressly authorize my agent (and alternate agent) to make decisions_______________. (address and telephone of alternate 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 ereby appoint: ______________________________________________________ (name of alternate attorney-in-fact) of _______________________________________________ __________________________________________ out my specific and general instructions and desires 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 h___________________________________________________________ (address and telephone of attorney-in-fact) as my attorney-in-fact to have the authority hereinafter set forth in order to express and carryegoing paragraphs concerning the legal consequences of my executing this document. I hereby appoint: ____________________________________________________________ (name of attorney-infact) of ___________________________________________, (name of principal) of __________________________________________________________, (address) state and affirm that I am an adult of sound mind and have read the fort 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. -1- Power of Attorney I, _______________________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) direcvocation. 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 ted 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 rere. 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 stadiagnose 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 desiped 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, 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 stopr 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 ons 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 youl 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 decisise of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -5- Power of Attorney for Health Care WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legaconsult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and uould not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also s. [_]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 starting point for you and shal. [_] 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 legal effect or completenesower of attorney for health care as provided in this part may be terminated or revoked only pursuant to this section and shall not be affected by the existence of a living will executed by the principbility for acting in good faith reliance upon such durable power of attorney unless the person has actual knowledge of the revocation. (g) The authority of an attorney in fact acting under a durable pth care decisions for the principal. (f) If authority granted by a durable power of attorney for health care is revoked under this section, a person is not subject to criminal prosecution or civil liarable power of attorney for health care the principal's marriage is dissolved or annulled, the dissolution or annulment revokes any designation of the former spouse as an attorney in fact to make healtorney for health care revokes any prior durable power of attorney for health care. -4- (e) Unless the durable power of attorney for health care expressly provides otherwise, if after executing a dul has the capacity to revoke a durable power of attorney for health care. This presumption is a presumption affecting the burden of proof. (d) Unless it provides otherwise, a valid durable power of atprovider shall make the notification a part of the principal's medical records and shall make a reasonable effort to notify the attorney in fact of the revocation. (c) It is presumed that the principaor in writing. (b) If the principal notifies the health care provider orally or in writing that the authority granted to the attorney in fact to make health care decisions is revoked, the health care lth care by notifying the attorney in fact orally or in writing; or (2) Revoke the authority granted to the attorney in fact to make health care decisions by notifying the health care provider orally The principal may, after executing a durable power of attorney for health care, do any of the following: (1) Revoke the appointment of the attorney in fact under the durable power of attorney for heament. The failure to include the warning statement in the document shall not affect the validity of the document (see enclosed notice found at the beginning of the document): 34-6-207. Revocation. (a)103(6). 34-6-205. Warning Statement. If a person other than the principal prepares a durable power of attorney for health care for the principal, the document shall contain the following warning state). The decision to withhold or withdraw health care may be made by the attorney in fact permitting the principal to die naturally with only the administration of palliative care as defined in § 32-11-are, the attorney in fact designated in such durable power of attorney may make health care decisions as provided in this part for the principal who has a terminal condition as defined in § 32-11103(9ower of attorney for health care, to make or participate in the making of health care decisions on behalf of the principal. (d) Subject to any limitations in the durable power of attorney for health c7; and (3) Directing the disposition of remains pursuant to title 68, chapter 4. (c) Nothing in this part affects any right the person designated as attorney in fact may have, apart from the durable pking a disposition under the Uniform Anatomical Gift Act, compiled in title 68, chapter 30; -3- (2) Authorizing an autopsy pursuant to the Post Mortem Examination Act, compiled in title 38, chapter cipal, before or after the death of the principal, to the same extent as the principal could make health care decisions for such principal if the principal had the capacity to do so, including: (1) Marincipal. (b) Subject to any limitations in the durable power of attorney for health care, the attorney in fact designated in such durable power of attorney may make health care decisions for the prin notwithstanding the provisions of the Uniform Durable Power of Attorney Act, compiled in part 1 of this chapter, which authorizes the fiduciary to revoke or amend a power of attorney created by the phealth care executed by the principal prior to such appointment; nor (ii) Replace the attorney in fact designated in such durable power of attorney. (B) The provisions of this subdivision (a)(2) applycourt of the principal's domicile appoints a conservator, guardian of the estate, or other fiduciary, such fiduciary shall not have the power to: (i) Revoke or amend the durable power of attorney for re decisions has priority over any other person to act for the principal in all matters of health care decisions. (2) (A) If, following the execution of a durable power of attorney for health care, a acting on behalf of the principal in bad faith, the attorney in fact designated in such durable power of attorney who is known to the health care provider to be available and willing to make health cas. (a) (1) Unless the durable power of attorney for health care provides otherwise, or unless a court with appropriate jurisdiction finds by clear and convincing evidence that the attorney in fact is 1) The employee so designated is a relative of the principal by blood, marriage or adoption; and (2) The other requirements of this part are satisfied. 34-6-204. Attorney in fact - Powers - Limitationcare provider or an employee 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 if: (nder any will or codicil thereto of the principal existing at the time of execution of the durable power of attorney or by operation of law then existing. -2- (f) An employee of the treating health e (1) of the following: (1) A relative of the principal by blood, 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 u) The operator of a health care institution; or (5) An employee 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 onalth care." (d) None of the following may be used as a witness under subsection (a): (1) A health care provider; (2) An employee of a health care provider; (3) The person named as attorney in fact; (4wer of attorney and the applicable law, and the consequences of signing or not signing this power of attorney, and my client, after being so advised, has executed this durable power of attorney for he this power of attorney was executed, and the principal was my client at the time this power of attorney was executed. I have advised my client concerning my client's rights in connection with this poconservatee is represented by legal counsel; and (3) The attorney representing the conservatee signs a certificate stating in substance: "I am an attorney authorized to practice law in the state wherere executed by a person who is a conservatee under the laws of this state where the conservatee has the power to execute legal documents, unless: (1) The power of attorney is otherwise valid; (2) The der becomes the principal's treating health care provider. (c) A conservator may not be designated as the attorney in fact to make health care decisions under a durable power of attorney for health ca power of attorney for health care; and -1- (2) A health care 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 proviovider, nor an operator of a health care institution nor an employee of an operator of a health care institution may be designated as the attorney in fact to make health care decisions under a durable a will or codicil thereto now existing, or by operation of law." (b) Except as provided in subsection (f): (1) Neither the treating health care provider nor an employee of the treating health care prion 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 the estate of the principal upon the death of the principal underor of a health care institution; that I am not related to the principal by blood, marriage, or adoption; that, to the best of my knowledge, I do not, at the present time, have a claim against any portrson 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 of a health care institution nor an employee of an operate principal; that the principal signed this durable power of attorney 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 pe each witness making the following declaration in substance: "I declare under penalty of perjury under the laws of Tennessee that the person who signed this document is personally known to me to be thtorney for health care is signed and acknowledged before a notary public by the principal and is signed by at least two (2) witnesses who witnessed the signing of the instrument by the principal, with(2) The durable power of attorney for health care contains the date of its execution; and (3) The durable power of attorney for health care is executed by the following method: the durable power of atare decisions unless all of the following requirements are satisfied: (1) The durable power of attorney for health care specifically authorizes the attorney in the fact to make health care decisions; essee Statutes relating to the Tennessee Power of Attorney for Health Care Form. 34-6-203. Requirements. (a) An attorney in fact under a durable power of attorney for health care may not make health cttorney for Health Care Form. This Tennessee Power of Attorney for Health Care is based on Title 34 Chapter 6 Section 34-6207 of the Tennessee Statutes. The following are useful excerpts from the TennInformation and Instructions Tennessee Power of Attorney for Health Care This package contains (1) Information and Instruction for Tennessee Power of Attorney for Health Care; (2) Tennessee Power of A Tennessee