Tennessee Medical Power of Attorney Form

The Tennessee medical power of attorney form is a legal document that would allow an Agent, selected by the Principal to oversee the health care decisions made in the event the Principal shall become incapacitated or disabled rendering them unable to communicate their own health care wishes. Until the Principal is no longer able to make their own decisions, they will remain in complete control of their health care decisions made with their health care providers. The Principal, while executing this document must be certain to specify any and all of their personal decisions, so as to be certain that their decisions are honored if/when, their decisions must depend upon their Agent.

This document should be carefully reviewed by the Principal inasmuch as, the Agent may be able to withdraw life sustaining treatments that the Principal may choose to continue or the Agent may add treatments that the Principal may not wish to have administered to them. If the Principal does not fully understand what they are preparing to sign, it’s strongly recommended that the Principal consider speaking with a competent attorney to clarify any lingering concerns they may have.

The document must be signed by two witnesses and all signatories must sign the document before a Notary Public. This document may also be revoked at any time by the Principal in writing to the Agent.

How to Write –

Step 1 – Establish Appointment of Agent(s) –

  • Enter the full name of the delegated Agent selected by the Principal

Step 2 – Successor Agent – In the event that the original Agent becomes unwilling or unable to serve in the capacity required, then the Principal may wish to speak with another person who would agree to serve consecutively. Once a Successor Agent is established, enter:

  • The full name of the Successor Agent

Step 3 – Signatures – Signatories must appear before a Notary Public for acknowledgement of the document – Submit the following:

  • The date of execution of the document in dd/mm/yyyy format
  • Print the Principal’s name
  • Address
  • Telephone Number
  • Enter the Principal’s signature
  • AND

Witness Attestation and Signatures –

  • The witnesses must first carefully read the attestation paragraph
  • If the Witnesses are in agreement with the information provided each witness must submit their respective signatures

Notarization –

As the Notary Public has had the opportunity to witness the signatures of the Principal and Witnesses, the Notary must complete the document with state required information that will acknowledge the validity of the document. The Notary shall then affix their official stamp or seal