Tennessee Advance Health Care Directive (Living Will) Form
	Adobe PDF MS Word

The Tennessee advance health care directive(living will) is a legal document that protects the rights of any person (Principal) to have all life-sustaining medical treatment withdrawn so that they may die naturally, should the Principal become unable to make or communicate any choices pertaining to their personal medical treatment selections. This document must be read, completed and signed while the Principal is of sound mind and witnessed by two witnesses OR notarization. The Principal may revoke their document for any reason at any time.

Laws – 32-11-101, et seq. Right to Natural Death Act

How to Write

Step 1 – Establish the Principal’s Document –

• Enter the Principal’s name into the first line of the document

Step 2 – Agent – If the principal would like to establish a health care agent, submit the following:

• Agents full name
• Telephone number
• Relation to the Principal
• Complete address
• AND

In case the first health care agent is unable or unwilling to continue service, establish an alternate agent by providing the following information:

• Agents full name
• Telephone number
• Relation to the Principal
• Complete address

Step 3 – When Effective –

• Read the statements and mark the applicable response

Step 4 – Quality of Life –

• Read the statements in this section and mark “yes” or “no” as to what the Principal would consider acceptable or unacceptable to their quality of life

Step 4 – Treatment –

• Read the statements in this section. Mark the appropriate “yes” or “no” answer regarding what the Principal would like to accept or decline

Step 5  – Other instructions, (ie: such as burial arrangements, hospice care)

• Enter any further instructions into the lines provided, add sheets if needed

Step 6 – Organ Donation –

• Mark the appropriate box
• Enter specific preferences into the lines provided

Step 7 – Signatures –

• The Principal must enter their signature
• Date the Principal’s signature

Witnesses –

• The witnesses must read the witness statement on the left of the page
• Witnesses Signatures
• OR
• If the Principal would prefer to have the document witnessed by a notary public, the notary will need to witness and record the Principal’s signature
• The notary will then complete the notary section of the form, provide their signature and affix their official seal or stamp
• Provide a copy of the document to your physician(s)
• The Principal should keep a copy in their personal files where it would be accessible to others
• The Principal should tell their closest relatives and friends what is in the document
• The Principal must provide a copy to the person(s) you named as their health care agent