Georgia Advanced Directives For Health Care Form (Page 3 of 9) in pdf

Georgia Advanced Directives For Health Care Form Page 3

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

(3) GEIIERAL POWERS OF ITEALTH CARE AGENT

Myhealth care agent will make health care decisions forme when I am unable to communicate

health care decisions or I choose to have my health care agent commuaicate my health

care

decisions-

My health care agent will have the same authority to make any health care decision that I would

make. Myhealth care agent's authority includes, for example, the powerto:

Admit me to or.discharge me from any hospital, skilled nursing faclllty,hospice or other

health care facility or senrice;

Request, consent to, or witlhold, or withdraw any type of health care; and

Conkact for any 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 tiable io, *y services

or care

contracted for me or on mybehalf).

My health care agent will be my personal representative for all pu4)oses of federal or state

law

related to privacy ofmedical records (including the Health Insurance Portabilitv and Acco'ntabili*,

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 caxe agent may accompany 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 hospital, skilled nursing facility, hospita! 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 care 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;

Page 3 of9 pagds.

Georgia Advanced Directives For Health Care Form Page 3