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Georgia Print Name: _______________________________________________________________ Address: _______________________________________________________________ Georgia Advance Health Care Directive 8 ___________________________ Address: _______________________________________________________________ ___________________________________________ (Signature of Second Witness) _______________ (Date) care and signed this form willingly and voluntarily. ___________________________________________ (Signature of First Witness) _______________ (Date) Print Name: ____________________________________m in my presence or acknowledged signing this form to me. Based upon my personal observation, the declarant appeared to be emotionally and mentally capable of making this advance directive for health ance directive for health care and that I understand its purpose and effect. ___________________________________________ (Signature of Declarant) _______________ (Date) The declarant signed this ford in your health care).] (REMAINDER OF PAGE INTENTIONALLY LEFT BLANK) Georgia Advance Health Care Directive 7 By signing below, I state that I am emotionally and mentally capable of making this advee, agent, or medical staff member of the hospital, skilled nursing facility, hospice, or other health care facility in which you are receiving health care (but this witness cannot be directly involveit anything from you or otherwise knowingly gain a financial benefit from your death; or · Cannot be a person who is directly involved in your health care. · Only one of the witnesses may be an employ with you when you sign this form. A witness: · Cannot be a person who was selected to be your health care agent or back-up health care agent in PART ONE; · Cannot be a person who will knowingly inherwledge signing and dating this form in the presence of two witnesses. Both witnesses must be of sound mind and must be at least 18 years of age, but the witnesses do not have to be together or presentPART ONE). __________ (Initials) This advance directive for health care will become effective on or upon ________________ and will terminate on or upon _______________. You must sign and date or acknos or events, this advance directive for health care will become effective at the time I sign it and will remain effective until my death (and after my death to the extent authorized in Section (5) of ealth care, durable power of attorney for health care, health care proxy, or living will that I have completed before this date. Unless I have initialed below and have provided alternative future dateATURES This advance directive for health care will become effective only if I am unable or choose not to make or communicate my own health care decisions. This form revokes any advance directive for h_________________ Telephone Numbers: ______________________________________________________________ (Home, Work, and Mobile) Georgia Advance Health Care Directive 6 PART FOUR: EFFECTIVENESS AND SIGN________ (Initials) I nominate the following person to serve as my guardian: Name: ______________________________________________________________ Address: _____________________________________________ling (A) or (B). Choose (A) only if you have also completed PART ONE.] (A) __________ (Initials) I nominate the person serving as my health care agent under PART ONE to serve as my guardian. OR (B) __rdian are not the same person, your health care agent will have priority over your guardian in making your health care decisions, unless a court determines otherwise.] [State your preference by initia your best interest and welfare. If you have selected a health care agent in PART ONE, you may (but are not required to) nominate the same person to be your guardian. If your health care agent and gua significant responsible decisions for yourself regarding your personal support, safety, or welfare. A court will appoint the person nominated by you if the court finds that the appointment will serverson to be your guardian in the event a court decides that a guardian should be appointed, complete PART THREE. A court will appoint a guardian for you if the court finds that you are not able to make not viable. PART THREE: GUARDIANSHIP (10) GUARDIANSHIP [PART THREE is optional. This advance directive for health care will be effective even if PART THREE is left blank. If you wish to nominate a pe effect if I am pregnant unless the fetus is not viable and I indicate by initialing below that I want PART TWO to be carried out. _________ (Initials) I want PART TWO to be carried out if my fetus isdvance Health Care Directive 5 (9) IN CASE OF PREGNANCY [PART TWO will be effective even if this section is left blank.] I understand that under Georgia law, PART TWO generally will have no force and___________________________________________________________ ________________________________________________________________ ________________________________________________________________ Georgia A your health care agent (if you have selected a health care agent in PART ONE) about following your treatment preferences. You may want to state your specific preferences regarding pain relief.] _____usion, or kidney dialysis. Understanding that you cannot foresee everything that could happen to you after you can no longer communicate your treatment preferences, you may want to provide guidance tour personal and religious values about your medical treatment. For example, you may want to state your treatment preferences regarding medications to fight infection, surgery, amputation, blood transfllows you to state additional treatment preferences, to provide additional guidance to your health care agent (if you have selected a health care agent in PART ONE), or to provide information about yohas stopped, I want to have cardiopulmonary resuscitation (CPR) used. (8) ADDITIONAL STATEMENTS [This section is optional. PART TWO will be effective even if this section is left blank. This section ads by mouth, I want to receive fluids by tube or other medical means. _________ (Initials) If I need assistance to breathe, I want to have a ventilator used. _________ (Initials) If my heart or pulse nt to apply to option (C).] _________ (Initials) If I am unable to take nutrition by mouth, I want to receive nutrition by tube or other medical means. _________ (Initials) If I am unable to take flui I do not want any medications, machines, or other medical procedures that in reasonable medical judgment could keep me alive but cannot cure me, except as follows: [Initial each statement that you waal judgment could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication. OR (C) _________ (Initials)ion or fluids by tube or other medical means. OR (B) _________ (Initials) Allow my natural death to occur. I do not want any medications, machines, or other medical procedures that in reasonable medicmedical procedures that in reasonable medical Georgia Advance Health Care Directive 4 judgment could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutritn made to communicate with me about my treatment preferences, then: (Choose only one) (A) _________ (Initials) Try to extend my life for as long as possible, using all medications, machines, or other n relief in the next section.] If I am in any condition that I initialed in Section (6) above and I can no longer communicate my treatment preferences after reasonable and appropriate efforts have beeinstructions about your treatment preferences in the next section. You will be provided with comfort care, including pain relief, but you may also want to state your specific preferences regarding paitialing (A), (B), or (C).(you can choose only one) If you choose (C), state your additional treatment preferences by initialing one or more of the statements following (C). You may provide additional g after personal examination by my attending physician and a second physician in accordance with currently accepted medical standards. (7) TREATMENT PREFERENCES [State your treatment preference by ini means I am in an incurable or irreversible condition in which I am not aware of myself or my environment and I show no behavioral response to my environment. My condition will be determined in writincondition, which means I have an incurable or irreversible condition that will result in my death in a relatively short period of time. _________ (Initials) A state of permanent unconsciousness, whichf PART ONE.] (6) CONDITIONS PART TWO will be effective if I am in any of the following conditions: [Initial each condition in which you want PART TWO to be effective.] _________ (Initials) A terminal hority to make all health care decisions for you regarding matters covered by PART TWO. Your health care agent will be guided by your treatment preferences and other factors described in Section (4) oART TWO will provide your physician and other health care providers with your treatment preferences. If you have selected a health care agent in PART ONE, then your health care agent will have the autour treatment preferences. PART TWO will be effective even if PART ONE is not completed. If you have not selected a health care agent in PART ONE, or if your health care agent is not available, then PEATMENT PREFERENCES [PART TWO will be effective only if you are unable to communicate your treatment preferences after reasonable and appropriate efforts have been made to communicate with you about y______________________________ (Home, Work, and Mobile) I wish for my body to be: __________ (Initials) Buried OR __________ (Initials) Cremated Georgia Advance Health Care Directive 3 PART TWO: TRody: Name: _______________________________________________________________ Address: _______________________________________________________________ Telephone Numbers: _________________________________he power to make decisions about the final disposition of my body unless I have initialed below. __________ (Initials) I want the following person to make decisions about the final disposition of my by body for use in a medical study program. __________ (Initials) My health care agent will not have the power to donate any of my organs. (C) FINAL DISPOSITION OF BODY My health care agent will have tlimited my health care agent's power by initialing below. [Initial each statement that you want to apply.] __________ (Initials) My health care agent will not have the power to make a disposition of mATION AND DONATION OF BODY My health care agent will have the power to make a disposition of any part or all of my body for medical purposes pursuant to the Georgia Anatomical Gift Act, unless I have alth care agent's power by initialing below. __________ (Initials) My health care agent will not have the power to authorize an autopsy of my body (unless an autopsy is required by law). (B) ORGAN DONent circumstances and treatment options. (5) POWERS OF HEALTH CARE AGENT AFTER DEATH (A) AUTOPSY My health care agent will have the power to authorize an autopsy of my body unless I have limited my heould decide is still unclear, then my health care agent should make decisions for me that my health care agent believes are in my best interest, considering the benefits, burdens, and risks of my curr(if I have filled out PART TWO), my religious and other beliefs and values, and how I have handled Georgia Advance Health Care Directive 2 medical and other important issues in the past. If what I when making health care decisions for me, my health care agent should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in PART TWO r me regarding psychosurgery, sterilization, or treatment or involuntary hospitalization for mental or emotional illness, mental retardation, or addictive disease. (4) GUIDANCE FOR HEALTH CARE AGENT Wcourt can take away the powers of my health care agent if it finds that my health care agent is not acting properly; and · My health care agent does not have the power to make health care decisions fo in lieu of the original and the copy will have the same meaning and effect as the original. I understand that under Georgia law: · My health care agent may refuse to act as my health care agent; · A pital, skilled nursing facility, hospice, or other health care facility or service if its protocol permits visitation. My health care agent may present a copy of this advance directive for health careompany me in an ambulance or air ambulance if in the opinion of the ambulance personnel protocol permits a passenger and my health care agent may visit or consult with me in person while I am in a hoslity Act of 1996) and will have the same access to my medical records that I have and can disclose the contents of my medical records to others for my ongoing health care. My health care agent may accalf). My health care agent will be my personal representative for all purposes of federal or state law related to privacy of medical records (including the Health Insurance Portability and Accountabiny health care facility or service for me, and to obligate me to pay for these services (and my health care agent will not be financially liable for any services or care contracted for me or on my beho or discharge me from any hospital, skilled nursing facility, hospice, or other health care facility or service; Request, consent to, withhold, or withdraw any type of health care; and Contract for adecisions. My health care agent will have the same authority to make any health care decision that I could make. My health care agent´s authority includes, for example, the power to: · · · Admit me tLTH CARE AGENT My health care agent will make health care decisions for me when I am unable to communicate my health care decisions or I choose to have my health care agent communicate my health care _______________________ Telephone Numbers: ________________________________________________________________ (Home, Work, and Mobile) Georgia Advance Health Care Directive 1 (3) GENERAL POWERS OF HEA____________________________________________________ (Home, Work, and Mobile) Name: ________________________________________________________________ Address: _________________________________________p health care agent(s): Name: ________________________________________________________________ Address: ________________________________________________________________ Telephone Numbers: ____________orts or for any reason my health care agent is unavailable or unable or unwilling to act as my health care agent, then I select the following, each to act successively in the order named, as my back-us section is optional. PART ONE will be effective even if this section is left blank.] If my health care agent cannot be contacted in a reasonable time period and cannot be located with reasonable eff_______________________________________________________ Telephone Numbers: ________________________________________________________________ (Home, Work, and Mobile) (2) BACK-UP HEALTH CARE AGENT [Thi HEALTH CARE AGENT I select the following person as my health care agent to make health care decisions for me: Name: ________________________________________________________________ Address: _________orm. GEORGIA STATUTORY SHORT FORM ADVANCE DIRECTIVE FOR HEALTH CARE By: ________________________________ Date of Birth: ________________ (Print Name) (Month/Day/Year) PART ONE: HEALTH CARE AGENT (1)e. This completed form will replace any advance directive for health care, durable power of attorney for health care, health care proxy, or living will that you have completed before completing this fe. Using this form of advance directive for health care is completely optional. Other forms of advance directives for health care may be used in Georgia. You may revoke this completed form at any timan easily be found if it is needed. Review this completed form periodically to make sure it still reflects your preferences. If your preferences change, complete a new advance directive for health carshould give a copy of this completed form to people who might need it, such as your health care agent, your family, and your physician. Keep a copy of this completed form at home in a place where it c of this form. PART TWO PART THREE PART FOUR You may fill out any or all of the first three parts listed above. You must fill out PART FOUR of this form in order for this form to be effective. You ardian should one ever be needed. EFFECTIVENESS AND SIGNATURES. This part requires your signature and the signatures of two witnesses. You must complete PART FOUR if you have filled out any other partrences before PART TWO becomes effective. You should talk to your family and others close to you about your treatment preferences. GUARDIANSHIP. This part allows you to nominate a person to be your guess. PART TWO will become effective only if you are unable to communicate your treatment preferences. Reasonable and appropriate efforts will be made to communicate with you about your treatment prefeare agent about this important role. TREATMENT PREFERENCES. This part allows you to state your treatment preferences if you have a terminal condition or if you are in a state of permanent unconsciousnalso have your health care agent make decisions for you after your death with respect to an autopsy, organ donation, body donation, and final disposition of your body. You should talk to your health cs you to choose someone to make health care decisions for you when you cannot (or do not want to) make health care decisions for yourself. The person you choose is called a health care agent. You may d be consulted for all serious legal matters. Instructions for Georgia Advance Health Care Directive This advance directive for health care has four parts: PART ONE HEALTH CARE AGENT. This part allowowever caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney shouldirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) hd at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, interials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are usee of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These maapacity. A power of attorney for health care appoints an individual to make health care decisions, should the principal be unable to do so. Disclaimer No Attorney-Client relationship is created by usill covers specific directions as to the course of treatment that is to be taken by caregivers, or in some cases forbidding treatment should the principal be unable to give informed consent due to incGeorgia Advance Health Care Directive This package contains a Georgia Advance Health Care Directive. It combines provisions of a living will and a durable power of attorney for health care. A living w Georgia