Get Tn Appointment Of Health Care Agent 2005-2025

APPOINTMENT OF HEALTH CARE AGENT Tennessee I give my agent named below permission to make health care decisions for me if I cannot make decisions for myself including any health care decision that I could have made for myself if able. If my agent is unavailable or is unable or unwilling to serve the alternate named below will take the agent s place. Agent Alternate Name Address City State Area Code Work Phone Number Home Phone Number Date Zip Code Mobile Phone Number Patient s name please print or type Signature of patient must be at least 18 or emancipated minor To be legally valid either block A or block B must be properly completed and signed* --------------------------------------------------------------------------------------------------------------------------------------------------------Block A Witnesses 2 witnesses required 1. I am a competent adult who is not named above. I witnessed the patient s signature on this form* related to the patient by blood marriage or adoption and I would not be entitled to any portion of the patient s estate upon his or her death under any existing will or codicil or by operation of law. I witnessed the patient s signature on this form* Signature of witness number 1 Notarization STATE OF TENNESSEE COUNTY OF I am a Notary Public in and for the State and County named above. The person who signed this instrument is personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is shown above as the patient. The patient personally appeared before me and signed above or acknowledged the signature above as his or her own* I declare under penalty of perjury that the patient appears to be of sound mind and under no duress fraud or undue influence. My commission expires Signature of Notary Public Approved by Tennessee Department of Health Board for Licensing Health Care Facilities February 3 2005. If my agent is unavailable or is unable or unwilling to serve the alternate named below will take the agent s place. Agent Alternate Name Address City State Area Code Work Phone Number Home Phone Number Date Zip Code Mobile Phone Number Patient s name please print or type Signature of patient must be at least 18 or emancipated minor To be legally valid either block A or block B must be properly completed and signed* --------------------------------------------------------------------------------------------------------------------------------------------------------Block A Witnesses 2 witnesses required 1. Agent Alternate Name Address City State Area Code Work Phone Number Home Phone Number Date Zip Code Mobile Phone Number Patient s name please print or type Signature of patient must be at least 18 or emancipated minor To be legally valid either block A or block B must be properly completed and signed* --------------------------------------------------------------------------------------------------------------------------------------------------------Block A Witnesses 2 witnesses required 1. I am a competent adult who is not named above. I witnessed the patient s signature on this form* related to the patient by blood marriage or adoption and I would not be entitled to any portion of the patient s estate upon his or her death under any existing will or codicil or by operation of law. .