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Tennessee Medical Power of Attorney Form

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Tennessee Medical Power of Attorney Form

Updated August 09, 2023

A Tennessee medical power of attorney form allows a principal to choose an attorney-in-fact to make health care decisions on their behalf. The principal also can choose to accept or forbid assistance to eat or drink. The attorney-in-fact can also be given powers to give treatment to keep the principal comfortable and out of pain. Additional attorneys-in-fact individuals may be added in case the primary person is not available.


(1) “Durable power of attorney for health care” means a durable power of attorney to the extent that it authorizes an attorney in fact to make health care decisions for the principal;


How to Write

Download: PDF

1 – Download The Template To Delegate Medical Powers

When it is time to issue Medical Authority to an Agent, download the template linked to the buttons under the preview picture. This paperwork is available as a PDF, ODT, or Word file.

2 – Supplement The Appointment With Agent Information

The left-hand box on the first page will present several blank lines that should be filled out. Locate the statement “I Want Them To Have The Power To…,” then enter the Name of the Principal’s Health Care Agent, Residential Street Address, City, and State on the blank lines labeled “Name,” “Street Address,” “City,” and “State.”Next, on the blank lines labeled “Day Time Phone” and “Night Time Phone” will require the Phone Numbers that can be used to contact the Health Care Agent relatively quickly. Now locate the heading labeled “Backup Attorney-in-Fact.” It is customary for a Principal to name someone to act as his or her Successor Agent in case, the Health Care Attorney-in-Fact cannot or will not wield the Principal Power delivered by this appointment. If the Principal desires such an Agent to be placed, then fill in the Backup Agent’s Name, Residential Address, Day Time Phone Number, and Night Time Phone Number using the blank lines supplied in this section.

3 – The Principal And Two Witnesses Must Sign This Directive Before A Notary

This box must be Dated and Signed by the Principal. He or she must enter the Signature Date using the spaces provided in the statement beginning with “I Am Signing This Durable Power Of Attorney For Health Care On The…”The Principal must sign the blank line labeled “My Signature” right after the “X”

4 – If The Principal Has A Living Will, It Must Be Addressed

The box on the right will address directives part of the Principal’s Living Will. Locate the bold words “Does My Doctor Think I will Die No Matter What They Do?” If the Principal will give the Agent the right to withdraw Food or Drink, then mark the box after the words “I Do.” If this decision should not be in the Agent’s Power, then mark the box after the words “…Do Not”The next set of boxes will define whether the Agent will have the Decision-Making Powers to decide if Treatment/Medication to keep the Principal comfortable at an end-of-life event should be administered or not. If the Agent should have this Decision-Making Powers, then mark the box labeled “I Do.” If not, then mark the box labeled “…Do Not”

5 – The Principal Must Supply A Separate Dated Signature If A Living Will Is Defined

If the Principal has had to mark his or her preferences in the second box because he or she has a Living Will, then the Principal must sign the blank line after the bold “X” then supply the Date of his or her Signature below this.

6 – The Principal Signing Must Be Witnessed or Notarized

Regardless of whether the Principal has signed this one or both parts of this document, his or her Signature must be Witnessed by two (2) individuals who are not related to him, have no beneficiary interests, and are not associated with his or her Health Care, or signed the principal may sign before a notary public. Thus, after he or she completes the act of signing, the Principal must release this paperwork to the two Witnesses or Notary.

If opting for both Witnesses, then each must read the statement at the top of the second page, sign his or her Name on the “Signature Of Witness” line, and supply the Date he or she signed it. Two separate Witness Signature lines have been provided so that each Witness will have a designated area to work with.

If choosing the Notary Public option, the principal shall release the document to the notary in attendance so that he or she may finalize this execution through its notarization